HEALTH  SCIENCES  STANDARD 


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A  TEXT-BOOK  OF 
SUEOEEY 


BY 

De.  HERMANN   TILLMAXNS 


PROFESSOR    IN    THE    TXIVERSITY    OF    LEIPSIC 


TRANSLATED  FRO 31  THE  SEVENTH  GERMAN  EDITION 

BY 

BEXJAMIX   T.   TILTOX,  M.  D. 

INSTRUCTOR    IN    SURGERY,    CORNELL    UNIVERSITY 
AXD 

JOHX   EOGEES,  M.  D. 

INSTRUCTOR    IN    SURGERY,    CORNELL    UNIVERSITY 


Edited  by  LEWIS   A.   STIMSOX,  M.  D. 

PROFESSOR    OF    SURGERY,    CORNELL    UNIVERSITY 


VOLUME   I 

THE  PEIXCIPLES   OF   SUEGERY 
AND   SURGICAL  PATHOLOGY 


WITH  FIVE  HUNDRED   AND    SIXTEEN  ILLUSTRATIOXS 


XEW    YOEK 
D.    APPLET  ox    AXD    COM  PAX  Y 

1901 


Copyright.   1894,  1897,   1901, 
By  D.   APPLETON   AND    COMPAXY. 


PREFACE   TO   VOLUME   I 


Since  the  first  English  translation  of  the  third  German  edition 
of  this  volume,  seven  years  ago,  four  new  German  editions  have 
appeared.  The  alterations  and  additions  made  necessary  in  the  latter 
by  I'ecent  progress,  chiefly  in  pathology  and  bacteriology,  have  been 
so  numerous  that  a  second  English  edition  is  now  urgently  required. 

The  division  of  text-books  of  surgery  into  separate  volumes  on 
general  and  regional  topics,  which  was  first  practised  exclusively  by 
German  and  French  writers,  has  now  become  the  custom  in  English 
and  American  works.  Such  an  arrangement  is  a  result  of  the 
great  advances  that  have  been  made  of  late  in  surgical  pathology 
and  bacteriology,  and  of  the  growing  appreciation  of  the  value 
of  these  fundamental  principles  to  the  student  and  practitioner  of 
surgery.  It  is  important  that  our  medical  students  should  have 
a  text-book  from  which  they  can  first  gain  a  thorough  knowledge 
of  the  principles  of  surgery  before  taking  up  surgical  diseases  and 
injuries  of  special  parts.  Furthermore,  the  surgeon  of  to-day,  who 
wishes  his  work  to  be  fruitful  of  the  best  results,  must  keep  pace 
with  the  advances  in  the  fundamental  sciences  underlying  his  art. 

The  present  volume  contains  not  only  a  complete  exposition  of 
general  surgical  pathology  and  bacteriology,  but  also  chajDters  on  dis- 
eases and  injuries  of  special  tissues,  with  their  treatment ;  tumours ; 
general  surgical  technique,  and  bandaging.  This  arrangement  leaves 
for  the  two  follomng  volumes  the  application  of  the  principles 
already  learned,  and  the  systematic  description  of  the  surgical  dis- 
eases and  injuries  of  the  different  regions. 

The  favourable  reception  given  to  the  work  in  this  country  will, 
it  is  hoped,  be  extended  to  this  new  edition,  from  which  much 
that  was  obsolete  has  been  eliminated,  ■  and  to  which  have  been 
added  the  results  of  the  latest  researches  in  surgical  pathology  and 
the  most  modern  development  of  general  surgical  technique. 

Benjamin  T.  Tilton. 
59  West  Thirty-sixth  Street. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofsurger01 


CONTENTS 


FIRST   SECTIOX. 

GENERAL  PRINCIPLES  GO  VERNING  SURGICAL  OPERA  TIONS. 
I.  The  Preparations  for  ax  Aseptic  Operation. 

SECTION  PAGE 

4.  Definition  of  a  surgical  operation 1 

5.  Indications  and  counter-indications  for  undertaking  an  operation  ...  3 

6.  The  preparations  for  an  "aseptic  operation.  Antisepsis  and  asepsis  ...  2 

II.  The  Alleviation  of  Pain  during  Operations. — General  and  Local 

Anaesthesia. 

7.  The  alleviation  of  pain  during  the  operation 17 

8.  Chloroform  narcosis .        .19 

9.  Technique  of  chloroform  narcosis 22 

10.  Symptomatology  of  chloroform  narcosis .  27 

11.  Accidents  occurring  during  chloroform  narcosis 29 

12.  The  occurrence  and  cause  of  death  during  narcosis 30 

13.  Treatment  of  common  accidents  occurring  during  chloroform  narcosis  .         .  36 

14.  Ether  narcosis 39 

15.  Laughing-gas  narcosis 44 

16.  Mixed  narcosis  and  other  anaesthetics 45 

17.  Local  anaesthesia 49 

III.  The  Prevention  of  Loss  of  Blood  during  an  Operation. 

18.  The  prevention  of  loss  of  blood  during  an  operation 53 

19.  Esmarch's  artificial  ischtemia      . 54 

IV.   General  Rules  for  performing  an  Aseptic  Operation  and  for 
the  After-treatment  of  the  Patient. 

20.  Performance  of  an  aseptic  operation 60 

21.  The  accidents  during  an  operation 61 

22.  The  post-operative  treatment  of  patients 66 

23.  The  most  important  causes  of  death  after  operation 67 

V.  The  Different  Wats  of  Dividing  the  Tissues. 

24.  The  division  of  the  soft  parts  (accompanied  by  the  loss  of  blood)     ...  69 

25.  Bloodless  division  of  the  tissues  without  cutting,  by  tearing,  twisting,  etc.       .  77 

26.  The  division  of  bone 86 


^j  CONTENTS. 

VI.   The  Methods  of  arresting  ILemorruage. 

SECTION  PAGE 

27.  The  arrest  of  hipmorrhage  during  operations 92 

28.  Substitutes  for  the  ligation  of  vessels 97 

29.  Other  inethods  of  hiiMuostasis .        .99 

30.  Ligation  of  arteries  in  continuity 101 

VII.   Drainage  of  "Wounds. 

31.  The  method  of  allowing  the  secretions  of  a  wound  to  escape    ....     105 

VIII.   The  Method  of  uniting  the  Tissues. — Suture  of  the  "Wound. 

32.  Disinfection  of  the  wound  before  inserting  the  sutures 110 

33.  The  method  of  uniting  the  soft  parts— Suture  of  the  wound    .         .        .         .111 

34.  The  method  of  uniting  wound  surfaces  of  bone 117 

IX.   Amputations,  Disarticulations,  and  Resections. — General  Considerations. 

35.  General  considerations  in  performing  amputations  and  disarticulations  .         .119 

36.  General  considerations  in  regard  to  amputations 120 

37.  The  method  of  performing  disarticulations 128 

38.  The  after-treatment  of  amputations  and  disarticulations 129 

39.  Artificial  limbs 133 

40.  Operations  on  joints 135 

X.  Operations  for  Remedying  Defects  in  the  Tissues.— Plastic 
Operations. — Transplantation. 

41.  Plastic  operations  for  cutaneous  defects 140 

42.  Skin-grafting  according  to  Reverdin  and  Thiersch 146 

43.  Plastic  operations  on  other  tissues 150 


SECOND   SECTION. 
THE  METHODS  OF  APPLYING  SURGICAL  DRESSINGS. 

I.   The  Antiseptic  and  Aseptic  Protective  Dressings. 


44.  General  principles  governing  antiseptic  or  aseptic  dressings     . 

45.  The  most  common  antiseptic  and  aseptic  dressings 

46.  The  different  antiseptics 

47.  Which  antiseptics  and  which  antiseptic  or  aseptic  dressings  are  the  best  ? 

48.  The  changing  of  an  antiseptic  or  an  aseptic  dressing        .... 

IT.    Other  ]\Iethods  of  treating  Wounds. 

49.  Other  dressings  for  wounds 


152 
154 
157 
173 
175 


180 


III.   General  Rules  for  the  Application  of  Bandages  and  Retention 

Appliances. 

50.  Application  of  bandages ^°'^ 

51.  Application  of  suitably  shaped  pieces  of  cloth  in  place  of  bandages        .         •     197 


\Y.   The  Sick-bed  of  the  Patient. — Immobilisation  Appliances  and  Dressings. 

52.  The  sick-bed  of  the  patient ^^^ 

53.  Sick-bed  appliances — Splints,  cushions,  etc -"5 


CONTENTS.  vii 

V.   The  Application  of  Immobilising  Dressings  made  of  Materials 

WHICH    GRADUALLY    HARDEN. 
SECTION  PAGE 

54.  Immobilisation  dressings  of  hardening  substances 217 

55.  The  method  of  applying  extension  by  a  weight 226 


THIRD  SECTION. 

SURGICAL  PATHOLOGY  AND    THERAPY. 

I.   Inflammation  and  Injuries. 

56.  Inflammation 233 

57o  Causes  of  Inflammation 240 

58.  Symptoms,  diagnosis,  and  treatment  of  inflammation 243 

59.  Morphology  and  general  significance  of  micro-organisms 254 

60.  General  remarks  concerning  injuries 283 

61.  The  anatomical  phenomena  in  the  healing  of  a  wound 286 

62.  The  general  reaction  which  follows  an  injury  and  an  inflammation. — Fever  .  305 

63.  Shock 319 

64.  Delirium  tremens 321 

65.  Delirium  nervosum  and  psychical  disturbances  which  may  follow  injuries  and 

operations 323 

66.  The  infectious-wound  diseases 323 

67.  Inflammation  and  suppuration  of  a  wound — Etiology 326 

68.  Lymphangitis,  lymphadenitis 333 

69.  Arteritis  and  phlebitis 335 

70.  Cellulitis .338 

71.  Erysipelas 346 

72.  Hospital  gangrene — Wound  diphtheria 358 

73.  Traumatic  tetanus 360 

74.  Septicaemia 369 

75.  Pyaemia 380 

76.  Infection  by  cadaveric  poisoning 386 

77.  Splenic  fever,  or  anthrax 388 

78.  Glanders,  or  farcy 397 

79.  Foot-and-mouth  disease 402 

80.  Plydrophobia 403 

81.  Poisoning  by  insects,  snakes,  etc 410 

82.  The  poisoning  of  wounds  by  Indian  arrow  poison 413 

Appendix.     Chronic  Mycoses  :   Tuherculosis  {Scrofula),  SypJiilis,  Leprosy, 

Actinomycosis. 

83.  Tuberculosis 414 

84.  Syphilis 435 

85.  Leprosy .450 

86.  Actinomycosis 455 

II.   Injuries  and  Surgical  Diseases  of  the  Soft  Parts. 

87.  Wounds  of  soft  parts 462 

88.  The  treatment  of  wounds  of  soft  parts 478 

89.  Treatment  of  the  conditions  following  severe  haemorrhages — Blood  and  com- 

mon salt  infusion 493 


viii  CONTENTS. 

SECTION  PAGE 

90.  Burns 499 

91.  ElTects  of  cold  (freezing) 509 

93.  Subcutaneous  injuries  of  soft  parts 518 

93.  The  diseases  of  the  skin  and  cellular  tissue 526 

94.  The  diseases  of  the  mucous  membranes 544 

95.  Inflammations  and  diseases  of  blood-vessels 551 

96.  The  diseases  of  the  lymphatic  system 564 

97.  The  diseases  of  the  peripheral  nerves 566 

98.  The  diseases  of  muscles,  tendons,  and  tendon-sheaths 569 

99.  The  diseases  of  the  bursa^ 580 

100.  Gangrene  (necrosis)  of  the  soft  parts 583 

III.   Injuries  and  Surgical  Diseases  of  Boxe. 

101.  Fractures 589 

102.  Contusions  and  wounds  of  bone 631 

103.  The  inflammations  of  bone 633 

104.  Acute  inflanimutioiis  of  bone — Acute  periostitis  and  acute  osteomyelitis       .  633 

105.  The  chronic  inflammations  of  bone 643 

106.  Necrosis  of  bone 655 

107.  Spontaneous  (inflammatory)  separations  of  the  epiphyses       ....  662 

108.  Rhachitis 663 

109.  Osteomalacia 669 

110.  Atrophy  and  hypertrophy  of  bone 672 

111.  The  tumours  of  bone 678 

IV.   Injuries  and  Diseases  of  Joints. 

112.  Review  of  the  anatomy  of  the  joints 681 

113.  The  acute  inflammations  of  joints 684 

114.  The  chronic  inflammations  of  joints 694 

115.  Joint-bodies  or  joint-mice 714 

116.  Neuroses  of   joints  (neuralgias  of   joints;    nervous,  hysterical   diseases   of 

joints) 718 

117.  Neuropathic  diseases  of  bones  and  joints 720 

118.  Anchylosis 724 

119.  Deformities  of  joints  (contractures) 726 

120.  Injuries  of  joints 736 

121.  Sprains  (distortions) 737 

122.  Dislocations  of  joints 739 

123.  Wounds  of  joints 752 

Apjjendix.     Gunshot  Wounds.     Military  Practice. 

124.  Gunshot  injuries 755 

V.   Tumours. 

125.  Tumours  in  general — definition  and  classification 769 

126.  Etiology  of  tumours 770 

127.  Growth,  course,  diagnosis,  and  treatment  of  tumours 773 

128.  The   different  varieties   of   tumours ;    connective-tissue  tumours  (fibroma, 

myxoma,  lipoma,  chondroma,  osteoma,  sarcoma,  etc.)          ....  779 

129.  The  epithelial  tumours  (papilloma,  epithelioma,  adenoma,  carcinoma,  etc.)     .  807 

130.  Cysts — AtheroiQa,  teratoma,  cyst-formation  in  different  tumours  .        .        .  825 


TILLMANNS'   PRINCIPLES   OF 
SURGERY   AND   SURGICAL   PATHOLOGY. 


FIRST  SECTION. 
GENERAL  PRINCIPLES  GOVERNING  SURGICAL  OPERATIONS. 


CHAPTER   I. 

THE    PREPARATIONS    FOR    Alf    ASEPTIC    OPERATION. 

a.  Definition  of  a  surgical  operation,  h.  The  indications  and  counter-indications  for 
undertaking  an  operation,  c.  Antisepsis  and  asepsis,  d.  The  preparations  for  an 
aseptic  operation. — Operating  room. — Operating  table. — Preparation  of  the  patient, 
the  operator,  and  his  assistants. — Sterilisation  of  the  instruments,  sponges,  gauze 
pads,  etc. — Preparation  of  aseptic  dressings. 

§  4.  Definition  of  a  Surgical  Operation. — An  "  operation,"  in  the 
broadest  sense  of  the  word,  means  any  mechanical  interference  of  the 
surgeon  undertaken  with  a  view  to  remedy  disease,  in  which  inter- 
ference surgical  instruments  are  used. 

A  distinction  is  made  between  an  operation  in  which  a  loss  of 
blood  occurs  and  one  in  which  it  does  not.  To  the  bloodless  opera- 
tions belong,  for  instance,  the  introduction  of  a  catheter  into  the 
bladder,  the  crushing  of  a  vesical  calculus  by  the  lithotrite,  the  re- 
moval of  foreign  bodies  from  the  external  auditory  meatus,  from  the 
pharynx,  etc.  But,  generally  speaking,  an  operation  is  ordinarily 
understood  to  be  of  the  kind  that  is  accompanied  by  a  loss  of  blood, 
and  this  is  the  kind  that  is  meant  here. 

"  Operative  surgery,"  says  Dieifenbach,  "  is,  of  all  branches  of  the 
healing  art,  the  most  suited  to  arouse  enthusiasm  in  its  followers ;  it  is 
a  bloody  fight  with  disease  for  life — a  fight  that  means  life  or  death." 
Every  surgeon  must  have  a  certain  amount  of  natural  talent,  and  an 
enthusiastic  devotion  to  his  profession.  A  complete  mastery  of  the 
technique,  keen  senses,  a  well-trained  eye,  a  delicate  touch,  and  a 
steady  hand,  are  all  indispensable.  The  plan  of  the  operation  must  be 
2  1 


2  THE   PREPARATIONS  FOR  AN  ASEPTIC  OPERATION. 

clearly  thought  out  beforehand,  and  during  the  operation  must  be 
quietly  and  resolutely  carried  out. 

^  5.  Indications  and  Counter-indications  for  an  Operation. — A  difficult 
problem  which  often  confronts  the  surgeon  is  to  correctly  weigh  the 
indications  and  counter-indications  for  undertaking  an  operation.  It 
is  often  a  hard  question  to  decide  whether  a  cure  is  not  possible  with- 
out an  operation ;  and  it  is  well  to  consider  whether  the  proposed 
operation  does  not  carry  with  it  greater  dangers  than  the  disease  itself, 
especially  in  those  cases  where  the  annoyances  are  but  slight.  The 
counter-indications  for  operation  depend  upon  the  particular  organ 
which  is  diseased  or  upon  the  general  condition  of  the  patient  (extreme 
youth  or  old  age,  general  weakness,  coexisting  acute  or  chronic  disease, 
etc.).  Under  all  circumstances  it  is  necessary  to  have  the  consent  of 
the  patient  for  the  proposed  operation. 

The  question  as  to  whether  an  operation  should  be  performed 
against  the  will  of  the  patient  is  answered  differently  by  different  sur- 
geons, though  the  majority  of  physicians  consider  that  they  are  entitled, 
and  indeed  obliged,  in  exceptional  cases,  to  perform  an  operation 
against  the  will  of  the  patient — if,  for  instance,  the  danger  from  the 
operation  is  much  less  than  that  from  the  continuation  of  the  disease, 
or  if  the  patient  can  be  saved  by  the  operation  from  certain  death. 

To  gain  the  desired  end  in  such  cases — or,  in  other  words,  to  per- 
form the  operation — the  patient  is  chloroformed,  and  upon  i-ecovering 
from  the  anaesthetic  he  is  usually  glad  that  the  operation  has  been 
done,  even  though  contrary  to  his  will. 

§  6.  Preparations  for  an  Antiseptic  or  Aseptic  Operation. — We  operate, 
without  exception,  according  to  either  antiseptic  or  aseptic  principles 
— that  is,  we  try  to  prevent  entrance  into  the  wound  of  substances 
that  tend  to  cause  inflammation  and  putrefaction.  All  the  decom- 
posing products  of  putrefaction  come  under  the  head  of  septic  matter 
— sepsis  (from  o-?}-\|ri9)  meaning  putrefaction.  An  antiseptic  operation 
is  one  in  which  antiseptic  solutions  are  used  to  kill  the  bacteria  that 
may  be  present  in  the  wound  or  enter  it  during  the  course  of  the  opera- 
tion. An  aseptic  operation  is  one  in  which  everything  that  is  to 
come  in  contact  with  the  wound  is  rendered  previously  germ  free,  and 
no  antiseptics  are  used  during  the  course  of  the  operation.  The  bac- 
teria that  cause  infection  of  wounds  exist  everywhere  ;  they  float  in 
the  air,  where  they  are  mixed  with  the  atmospheric  dust,  they  cling  to 
the  clothes  and  the  skin  of  the  patient  and  the  operator,  they  are  found 
on  the  instruments,  sponges,  etc.  Therefore,  if  we  wish  to  protect 
those  upon  whom  we  operate  from  the  noxious  influence  of  bacteria, 
we  must  take  the  greatest  pains  to  keep  the  latter  out  of  the  wound, 


§  6.]  THE  PREPARATIONS  FOR  AN  ASEPTIC   OPERATION.  3 

or,  if  they  have  already  found  lodgment  in  the  body,  to  check  their 
further  development,  and  to  destroy  them  as  soon  as  possible. 

The  preparations  for  an  aseptic  operation  must  be  so  managed  that 
every  possibility  of  infecting  the  wound  is  avoided.  Hence  we  must 
always  take  pains  to  most  rigidly  disinfect  the  operating  room,  the 
table,  the  part  to  be  operated  upon,  the  hands  and  clothes  of  the  oper- 
ator and  his  assistants,  the  instruments,  sponges,  and  dressings — in 
short,  everything  which  comes  into  direct  or  indirect  contact  with  the 
wound. 

Antisepsis  and  Asepsis. — During  operations  in  former  times,  anti- 
septics were  employed  much  too  freely — for  instance,  in  the  form  of  a 
mist,  the  so-called  spray,  or  in  the  form  of  irrigations — and  at  the 
close  of  the  operation  the  wound  was  once  more  energetically  disin- 
fected. Our  most  effective  antiseptics,  especially  carbolic  acid  and 
bichloride  of  mercury,  are  poisonous,  and  many  patients  have  died  after 
the  operation  of  carbolic  and  bichloride  poisoning.  The  too  intense 
irritation  of  antiseptics  endangers  the  vitality  of  the  tissues  with  which 
they  come  in  contact,  and  renders  them  less  capable  of  withstanding 
bacteria ;  furthermore,  serious  parenchymatous  lesions,  particularly  of 
the  kidney,  are  thus  produced  in  operations  within  the  thoracic  and 
peritoneal  cavities.  It  is  right,  therefore,  to  limit  the  use  of  antisep- 
tics in  operations ;  in  fact,  most  surgeons  aim  to  avoid  them  entirely. 
Disinfection  and  antiseptic  treatment  of  a  fresh  wound  which  has  been 
made  by  the  surgeon  is  not  necessary  if  the  operation  is  conducted 
strictly  aseptically — that  is,  if  the  field  of  operation,  the  hands  of  the 
surgeon,  the  instruments,  the  sponges  or  gauze  pledgets,  etc.,  have 
been  sterilised — i.  e.,  rendered  free  from  micro-organisms.  If  irriga- 
tion is  desirable,  a  sterilised  solution  of  common  salt  of  a  strength  of 
five  tenths  to  seven  tenths  per  cent.,  or  boiled  water,  should  be  substi- 
tuted for  the  carbolic  or  bichloride  solutions.  If  larger  amounts  of 
sterilised  water  are  needed,  the  apparatus  of  Fritsch  is  useful.  The  em- 
ployment of  a  six-tenths-per-cent.  sterilised  salt  solution  is  especially 
useful  in  laparotomies. 

Asepsis  has  taken  the  place  of  antisepsis  in  operations^  for  the  rea- 
son that  a  wound  which  has  not  been  irritated  by  antiseptics  heals 
much  more  readily,  the  secretion  is  much  less,  and  drainage  can  more 
frequently  be  entirely  dispensed  with.  Furthermore,  the  process  of 
repair  in  the  wound  is  quicker  with  the  aseptic  than  with  the  antiseptic 
method ;  the  aseptic  cicatrix  forms  sooner,  and  is  more  solid  and 
durable  than  when  the  wound  has  been  irritated  by  antiseptics.  When 
the  latter  have  been  used  the  process  of  cell  division  is  more  sluggish, 
and  begins  later. 


THE  PREPARATIONS   FOR  AN   ASEPTIC  OPERATION. 


In  the  ease  of  wounds  treated  bj  the  aseptic  method,  complete 
healing  and  tlie  formation  of  the  cicatrix  usually  occupies  eight  days  ; 
while  in  wounds  in  which  bichloride  of  mercury  has  been  used  the 
change  from  granulation  to  cicatricial  tissue  has  hardly  begun  in  this 
time. 

Socin,  Bergmann,  Xeuber,  and  others,  were  among  the  first  to  give 
up  antisepsis  for  asepsis,  though  Lawson  Tait  and  Koberle  had  long 
furnislied  proof  that  beautiful  operative  results  could  be  obtained 
without  using  antiseptic  solutions.  But  for  injuries  and  wounds  already 
infected,  the  rules  of  rigorous  antisepsis  are  to  be  carried  out — i.  e.,  the 
wound  should  be  thoroughly  disinfected  with  a  three-  to  five-per-cent. 
solution  of  carbolic  acid  or  one  tenth  to  one  fiftieth  per  cent,  of  bichlo- 
ride of  mercury,  I  am,  however,  of  the 
opinion  that  it  is  not  possible  to  really  disin- 
fect, with  our  usual  antiseptic  solutions,  a 
wound  that  has  once  become  infected.  The 
bacteria  present  in  the  tissues  are  not  acted 
upon  sufificiently  by  the  antiseptics — i.  e., 
they  are  not  killed.  The  chief  requirement 
in  infected  wounds  is  to  provide  for  sufficient 
escape  of  the  infected  secretions  by  incision 
and  drainage.  Moreover,  it  is  no  longer  the 
custom  to  use  dressings  that  have  been  im- 
pregnated with  bichloride  or  carbolic  acid. 
They  are  much  more  easily  and  surely  ster- 
ilised by  steam.  Dressings  impregnated  with 
antiseptics  are  often  found  after  a  time  to 
contain  bacteria.  Steam  sterilising  appara- 
tus have  now  been  universally  introduced 
in  hospitals  for  the  treatment  of  dressings, 
operating  gowns,  beds,  bed-clothing,  etc., 
and  small  steam  sterilising  apparatus  can 
easily  be  brought  into  every  large  surgical  ward.  The  portable  steam 
sterilisers  of  Straub,  H.  Settegast,  Bubenberg,  E.  Hahn,  and  Schimmel- 
busch  are  especially  adaptable  for  private  practice.  In  Fig.  1  is  illus- 
trated the  steriliser  of  Schimmelbusch.  As  regards  the  mechanism  of 
this  apparatus,  the  following  should  be  noted:  W,  the  part  which 
holds  the  water,  is  filled  by  a  funnel  through  the  tube  T,  up  to  a 
marked  height.  Whatever  is  to  be  sterilised  is  placed  in  the  inner 
compartment  of  the  apparatus,  the  latter  having  a  double  metallic  wall. 
The  cover  D  is  screwed  on  tight.  In  the  centre  of  the  cover  is  placed 
the  thermometer,  Th.     The  water  is  heated  by  a  gas  flame,  and  the 


Fig.  1. — Steam  sterilisiu^  appa- 
ratus (Schiminelbuscn). 


§6.] 


THE   PREPARATIONS  FOR  AN   ASEPTIC   OPERATION. 


Fig.  2.  —  Sheet- 
iron  vessel  for 
dressing  mate- 
rials (Schim- 
melbusch). 


Steam,  at  a  temperature  of  100°  to  130°  C.  (212°  to  266°  F.),  enters 
the  inner  compartment  of  the  apparatus  from    above,    and   escapes 
through  the  opening  H  into  a  lead  spiral  in  a  condenser  filled  with 
water.     The  air  between  the  double-walled  water  ves- 
sel and  the  metallic  enclosure,  which  is  protected  bj 
asbestos,  escapes  through  the  openings  at  0.     At  the 
end  of  the  sterilisation  the  water  can  be  drawn  off 
through  the  faucet  77,  the  cover  is  removed,  and  the 
sterihsed  article  taken  out.    In  order  that  the  sterilised 
dressings  can  be  kept  sterile,  the  tin  vessel  devised  by 
Schimmelbusch  (Fig.  2)  is  used.     This  is  provided  with 
a  tight  cover  {d)  and  a  great  number  of  holes  {a  h) ;  the 
latter  can  be  opened  and  closed  at  will  by  a  strip  of 
tin.     This  tin  vessel  is  filled  with  dressings  and  placed 
in  the  steriliser. 

We  shall  return  again  to  the  subject  of  sterilisation 
of  the  dressings,  operation  gowns,  compresses,  etc.,  and  presently 
describe  the  sterilisation  of  the  instruments  by  boiling  for  five  minutes 
in  a  one-per-cent.  soda  solution,  the  cleansing  of  the  hands,  etc.  For 
the  disinfection  of  large  articles,  such  as  mattresses,  clothes,  etc.,  the 
disinfector  of  Rietschel  and  Henneberg  is  particularly  good.  In  order 
to  be  sure  that  the  temperature  in  the  steriliser  reaches  a  sufficient 
height,  different  appliances  have  been  made  use  of.     For  example,  a 

bell  is  attached  which  rings  when  the  tem- 
perature reaches  130°  C,  or  small  glass  tubes 
containing  crystals  of  phthalic  acid,  or  alloys 
of  lead,  zinc,  and  bismuth,  which  melt  at  a 
temperature  of  110°  C,  are  inserted. 

Strehl  is  right  in  recommending  that  steril- 
isers which  are  heated  by  gas,  and  are  used  in 
the  operating  room  or  its  vicinity,  should  be 
supplied  with  an  arrangement  for  carrying  oflp 
the  gas,  in  order  that  the  air  in  the  operating 
room  may  not  be  contaminated  by  the  harmful 
gases,  and  the  danger  of  decomposition  of  the 
chloroform  (see  page  27)  may  be  avoided. 

The  cleanliness  of  the  operating  room 
and  of  everything  it  contains  must  always  be 
rigorously  enforced  by  the  surgeon. 
Operating  Room. — The  operating  room  should  be  as  light  as  possible, 
well  ventilated,  and  plentifully  supplied  with  arrangements  for  wash- 
ing, receptacles  for  disinfecting  solutions,  especially  three-  to  five-per- 


FlG. 


-Stand  for  solution 
bottles. 


6  THE  PREPARATIONS   FOR  AN  ASEPTIC  OPERATION. 

cent,  solutions  of  carbolic,  bichloride  (1  to  l,OU0-5,U00),  alcohol,  and 
sterile  salt  solution. 

Iron  stands  for  the  solution  bottles,  such  as  the  one  sho\vii  in  Fig.  3, 
are  very  useful. 

In  larger  hospitals  it  is  well  to  have  two  operating  rooms,  one  for 
aseptic  operations  and  the  other  for  infected  cases  ;  and  it  is  advantage- 
ous to  have  on  the  floor  of  the  oj^erathig  room,  which  is  best  made  of 
cement,  a  gutter  arrangement  for  conducting  oif  the  water. 

The  walls  of  the  operating  room  must  be  so  built  as  to  be  capable 
of  being  easily  and  thoroughly  cleansed,  and  therefore  should  be  cov- 
ered with  oil  or  enamel  paint,  or  with  metal  or  glass  plates.     Kecesses 


Fig.  4. — Author's  operating  table. 

and  corners  which  can  harbour  dust,  etc.,  are  to  be  avoided,  on  account 
of  the  microbes  they  contain,  and  pains  should  be  taken  not  to  stir  up 
dust  either  before  or  during  the  operation.  Before  an  operation  the 
air  in  the  room  can  be  moistened  by  steam  from  a  large  spray  or  steam 
pipe,  if  there  is  one,  and  thus  freed  of  dust. 

Operating  Table.— The  operating  table  should  be  as  simple  as  possible  and 
absolutely  clean.  In  order  to  facilitate  the  escape  of  soiled  liquids,  operating 
tables  are  coming  more  and  more  into  use  which  are  provided  with  means  to 
carry  ofip  these  fluids.  Operating  tables  made  with  an  iron  frame  and  a  glass 
plate  are  very  good.  My  own  operating  table,  illustrated  in  Fig.  4,  has  an 
iron  frame  with  a  plate  of  sti-ong  flint  glass ;  the  gutter  placed  around  the 
table  conducts  away  the  overflow  into  a  vessel  underneath,  and  the  whole 
table  can  be  readily  cleaned.     The  head-piece,  which  is  easily  adjusted,  is 


§6.] 


THE  PREPARATIONS  FOR  AN  ASEPTIC   OPERATION. 


Fig. 


-Author's  transportable  operating  table  for  private 
and  military  practice. 


fitted  with  a  removable  glass  plate.  For  elevating  the  pelvis,  a  movable 
framework  can  be  brought  into  use,  made,  like  the  head-piece,  of  glass  and 
iron,  and  leg-supporters  can  be  very  easily  attached.  I  have  also  devised  a 
transportable  table  with  folding  legs  for  private  practice  and  for  army  use 
(Figs.  5,  6,  and  7),  which 
is  made  of  wrought  iron, 
weighs  only  twenty -five 
kilogrammes,  and  is  inex- 
pensive. 

Trendelenburg  and 
■others  have  constructed 
tables  which  allow  the  pa- 
tient to  be  brought  into 
various  positions.  The 
table  invented  by  Knoke 
and  Dressier  (Figs.  8,  9, 
and  10)  is  an  excellent  one 
of  this  soi't.  For  pro- 
tracted operations — lapa- 
rotomies, for  instance — it 
is  advantageous  to  use  op- 
erating tables  which  can 
be  kept  warm,  such  as  me- 
tallic tables  (Socin)  filled 
with  hot  water.  In  this 
way  the  patient  is  kept 
from  losing  too  much 
body  temperatui'e. 

Preparation  of  the 
Patient.  —  The  prelimi- 
Tiaries  for  an  operation 
begin  with  the  prepara- 
tion of  the  patient.  In 
operations  of  any  mag- 
nitude the  whole  body 
should  be  first  thorough- 
ly cleansed  by  means  of 
a  warm  bath.  The  field 
of  operation  is  then  ren- 
dered aseptic  in  the  most 
scrupulous  manner.     If 

this  is  not  done  properly  the  success  of  the  operation  is  rendered 
doubtful  and  stitch-hole  abscesses  are  very  likely  to  occur,  even  when 
the  sutures  and  needle  are  aseptic.  The  skin  is  scrubbed  with  tincture 
of  green  soap  and  warm  water,  shaved,  rubbed  off  with  ether  in  order 
to  remove  the  fat  on  the  skin  and  the  micro-organisms  that  it  contains, 


Fig.  6. — Method  of  folding  up  the  table. 


i^ — 

jl 

j  1 1  f 

1                 /J 

2 y-I 

Fig.  7. 


-The  transportable   operating   table:  a,  seen   from 
below ;  b,  the  side ;  c,  the  end. 


8  THE   PREPARATIONS   FOR   AN   ASEPTIC   OPERATION. 

and  tinally  washed  with  a  three-  to  iive-per-eent.  solution  of  carbolic 
or  a  bichloride  solution  of  1  :  1,000  to  5,000.  The  scrubbing  and  dis- 
infecting of  the  hands  and  feet  especially  must  be  thoroughly  and  care- 


fully  carried  out.  Instead  of  brushes  which  are  boiled  and  kept  in  a 
bichloride  solution  (1  to  1,000),  I  use  swabs  of  wood  fibre  or  cotton 
which  are  sterilised  by  heat  and  burned  after  use. 

In  operations  in  the  mouth  the  teeth  should  he  thoroughly  cleansed 
by  a  toothbrush,  and  the  mouth  frequently  rinsed  with  a  chlorate-of- 
potash  solution  of  a  strength  of  5  or  6 
to  100,  or  permanganate  of  potassium, 
boric  acid,   etc.      Carious  teeth  and 


Fig   9. — Knoke  and  Dressler's  operating  table. 
Trendelenburg  position. 


Fig.   10. — Knoke  gnd    Jiressler's  operating 
table.     Lithotomy  position. 


the  tartar  which  swarms  with  bacteria,  etc.,  are  to  be  removed.  If 
the  operation  is  in  the  hypogastric  region,  in  the  neighbourhood 
of  the  anus,  on  the  urinary  and  sexual  organs,  or  in  the  peritoneal 


§6.] 


THE  PREPARATIONS   FOR  AN   ASEPTIC   OPERATION. 


Fig.  11. — Preparation  of  the 
patient  for  operations  on 
the  face  and  neck. 


cavity,  care  should  be  taken  to  secure  a  move- 
ment of  the  bowels  on  the  last  day  before  the 
operation  by  a  dose  of  castor  oil,  and  about 
two  hours  before  the  operation  the  rectum 
should  be  washed  out  with  lukewarm  water 
injected  from  an  irrigator.  When  necessary, 
the  bladder  should  be  emptied  in  advance  by  a 
catheter. 

The  stomach  of  a  patient  about  to  be  chloro- 
formed should,  if  possible,  be  empty,  and  in  all 
cases  the  taking  of  solid  food  shortly  before  the 
operation  should  be  forbidden,  so  that  the  re- 
spiratory movements  of  the  diaphragm  shall  not 
be  interfered  with,  and  troublesome  vomiting 
shall  not  occur.  The  entrance  of  vomited  matter  into  the  air-pas- 
sages has  repeatedly  caused  death  during  chloroform  narcosis. 

After  cleansing  and 
sterilising  the  field  of 
operation,  I  cover  the 
same  for  several  hours 
(if  time  permits)  mth  a 
moist  aseptic  dressing  of 
one-per-cent.  formalin. 
At  the  time  of  the  op- 
eration the  patient  is  cov- 
ered with  rubber  sheet- 
ing and  sterile  linen  com- 
presses, leaving  the  field 
of  operation  exposed 
(Figs.  11-14).  For  this 
purpose  the  protective 
coverings  are  provided 
with  openings  for  the 
arms,  legs,  and  neck,  or 
they  are  suitably  fast- 
ened together  with  safety 
pins.  The  linen  protect- 
ives  should  be  sterilised 
by  keeping  them  for  half 
an  hour  in  the  steriliser 
at  a  temperature  of  100° 

Fig.  14. — Position  of  the  patient  in  abdominal  operations.        tO    loO      O.       xlie    Sterile 


Fig.  12.- 


-Position  of  the  patient  in  operations  on  the  upper 
extremity. 


Fig.  13. — Position  of  the  patient  in  operations  on  the  lower 
extremity. 


10  THE  PREPARATIONS  FOR  AN  ASEPTIC  OPERATION. 

compresses  about  the  field  of  operation  may  in  addition  be  wrung  out 
in  l-to-l,0(M)  bichloride. 

In  operations  upon  the  face  and  neck  the  patient's  hair  should  be 
covered  by  a  rubber  cap,  which  is  made  to  fit  tightly  bj  means  of  an 
elastic  band,  so  as  to  prevent  the  hair  from  coming  in  contact  with 
the  field  of  operation  ;  or,  better  still,  the  head  may  be  wrapped  in  an 
aseptic  gauze  bandage. 

For  operations  in  the  peritoneal  cayitv,  it  is  better  to  provide  two 
protectives,  as  is  shown  in  Fig.  1-i.  Figs.  11  to  1-1  illustrate  sufii- 
cientlv  the  excellent  plan  which  has  been  recommended  by  Neuber. 

If  an  operation  is  protracted,  especially  in  cold  weather,  care  must 
be  taken  that  the  patient  does  not  become  chilled.  If  the  patient  be- 
comes badly  chilled,  a  dangerous  or  even  fatal  collapse  may  be  pro- 
duced, especially  after  operations  in  the  peritoneal  cavity.  For  this 
reason  it  is  wise  to  protect  the  patient  by  flannel  coverings,  warm  cloths, 
etc.,  and  particularly  by  warming  the  operating  room  to  about  16°- 
18°-19°  K.  {6S°  to  75°  F.).  For  protracted  operations  the  warmed 
operating  table  of  Socin,  already  mentioned,  is  valuable. 

The  best  clothing  for  the  operator  and  his  assistants  consists  of  a 
linen  operating  gown,  the  sleeves  of  which  only  reach  to  the  middle  of 
the  upper  arm.  Before  every  operation  the  freshly  washed  operating 
gowns  are  sterilised  for  a  half  to  three  quarters  of  an  hour  in  the 
steriliser  by  the  action  of  hot  steam  at  a  temperature  of  100°  C. 
(212°  F.).  With  a  view  to  preserving  thorough  asepsis,  the  operator 
and  his  assistants  must  work  with  bare  forearms. 

Sterilisation  of  the  Hands. — The  hands  and  forearms  are  disinfected 
in  the  following  manner :  While  dry,  the  nails  are  first  cleansed  of 
visible  dirt  by  a  nail  cleaner  and  scissors  which  are  always  kept  in  a 
ten-per-cent.  solution  of  carbolic  acid  in  glycerine  ;  then  the  hands  and 
forearms  are  thoroughly  scrubbed  with  a  brush  in  soap  and  warm  water, 
with  special  attention  to  the  ends  of  the  fingers  and  the  part  under- 
lying the  nails.  The  nailbrushes  are  sterilised  by  boiling  and  are 
kept  in  l-to-1,000  bichloride.  Coarse  white  or  gray  pumice  stone 
may  also  be  used  for  cleansing  the  hands.  The  latter  are  then  rubbed 
with  fifty-per-cent.  alcohol,  and  before  the  latter  evaporates  the  hands 
and  forearms  are  scrubbed  for  two  to  three  minutes  in  hot  l-to-1,000 
bichloride,  three-per-cent.  carbolic  acid,  three-quarters-per-cent.  creosol, 
or  one-per-cent.  formalin.  Finally  they  are  rubbed  with  a  gauze  com- 
press moistened  in  l-to-1,000  bichloride  or  one-per-cent.  formalin. 
The  bichloride  may  be  removed  by  treating  the  hands  with  sulphide 
of  ammonium  and  sterile  water.  It  is  of  the  greatest  importance  in 
disinfection  of  the  hands  to  soften  the  skin  thoroughly  by  means  of 


§6.]  THE   PREPARATIONS  FOR  AN   ASEPTIC   OPERATION.  H 

the  warm  water  and  to  clean  them  mechanicallj  with  nailbrushes,  so 
as  to  remove  the  bacteria  that  are  present  in  the  deeper  layers,  the 
glands,  etc.  Ether  or  alcohol  are  very  useful  in  dissolving  the  fat  on 
the  skin  and  thus  allowing  the  antiseptic  solutions  to  act  more  effec- 
tually. Quite  recently  a  number  of  tests  have  been  made  by  Saul, 
Paulj  Kronig,  riii'bringer,  Freyhan,  and  others  to  determine  the  anti- 
septic value  of  alcohol.  These  experiments  have  shown  varying  results. 
Most  of  the  authorities  have  come  to  the  conclusion  that  alcohol,  when 
used  in  too  concentrated  a  form,  diminishes  the  action  of  the  anti- 
septics such  as  bichloride,  but  that,  on  the  other  hand,  weak  alcoholic 
solutions  (twenty -five  to  fifty  per  cent.)  of  antiseptics  like  bichloride, 
carbolic,  lysol,  and  thymol  are  more  efficacious  than  aqueous  solutions 
of  the  same  strength.  Paul  and  Kronig  found  that  the  germicidal 
action  of  aqueous  solutions  of  bichloride  was  increased  by  the  addition 
of  twenty-five  per  cent,  ethyl  alcohol  or  by  methyl  alcohol  and  acetone, 
while,  on  the  other  hand,  the  action  of  aqueous  solutions  of  phenol  and 
formaldehyde  diminishes  vrith  every  addition  of  ethyl  alcohol  or  methyl 
alcohol.  Absolute  alcohol  possesses  no  strength  as  a  germicide,  and 
the  same  is  true  of  boiling  absolute  alcohol  (Saul).  It  follows  from 
this  that  in  disinfecting  the  hands  it  is  important  not  to  use  alcohol  in 
too  concentrated  a  form.  If  the  hands  are  rubbed  for  one  minute  in 
fifty-per-cent.  alcohol  as  described  above  and  then  placed  in  a  large 
basin  containing  l-to-1,000  bichloride,  the  germicidal  action  of  the  latter 
is  certainly  not  diminished  and  is  probably  increased.  In  fact,  I  con- 
sider the  use  of  diluted  alcohol  an  important  element  in  the  success  of 
my  method  of  sterilisation  of  the  hands.  Kronig  has  had  very  good 
results  with  the  following  method  of  disinfecting  the  hands  in  his 
gynaecological  clinic  in  Leipsic  :  After  trimming  and  cleaning  the  nails 
and  washing  the  hands  and  forearms  for  eight  minutes  in  warm  water, 
the  hands  and  forearms  are  placed  for  three  minutes  in  a  solution  con- 
taining one  per  cent,  permanganate  of  potash  and  one  half  per  cent, 
chlorine  water.  This  solution  is  prepared  as  follows :  45  cubic  centi- 
metres of  pure  hydrochloric  acid  (German  Pharmacopoeia,  twenty-five 
per  cent.)  are  well  mixed  with  1,600  cubic  centimetres  of  water,  and  to 
this  500  cubic  centimetres  of  a  four-per-cent.  permanganate-of -potash 
solution  are  added.  As  this  solution  attacks  metallic  and  enamelled 
vessels,  wooden  ones  should  be  used.  The  hands  and  forearms  are 
then  decolourised  in  a  warm  1.3-per-cent.  solution  of  oxalic  acid, 
and  finally  rinsed  off  in  sterile  water  in  order  to  lessen  the  irritating 
action  of  the  oxalic  acid.  For  keeping  the  hands  in  a  good  condi- 
tion. Pears'  glycerine  soap  is  particularly  useful,  and,  if  anything 
more  is  necessary,  the  inunction  of  a  small  amount  of  lanolin  is  excel- 


12  THE   PKEPAKATIONS   FOR  AN   ASEPTIC   OPEKATION. 

lent.  Modern  siii-<»:eons  should  give  up  wearing  rings,  and  in  any  case 
always  lay  them  aside  before  an  operation,  as  they  are  invariably 
bearers  of  infection.  I  do  not  use  the  operating  gloves  made  of  rub- 
ber, linen  thread,  silk,  etc.,  which  have  been  recommended  of  late  ; 
or  the  mouth  protectors  used  by  Mikulicz.  Why  should  we  cover 
our  hands,  which  have  already  been  made  sufficiently  aseptic,  with 
an  organic  material,  such  as  the  operating  gloves,  which,  according 
to  Doderlein,  are  more  likely  to  become  impregnated  Mith  bacteria 
than  the  hands  themselves  ?  In  septic  operations,  however,  and 
examinations  of  infected  wounds,  or  in  vaginal  examinations,  oper- 
ating gloves  are  of  use  as  a  means  of  protection  and  should  be 
used.  In  place  of  operating  gloves  Menge  has  recommended  covering 
the  hands  with  a  sterilised  solution  of  xylol  in  paraffine.  In  opera- 
tions that  must  be  performed  under  strictest  asepsis,  such  as  those  in 
the  peritoneal  cavity,  the  operator  and  his  assistants  should  talk  as  little 
as  possible,  because  we  have  learned  from  Fliigge's  investigations  that, 
in  speaking,  bacteria  pass  from  the  mouth  in  very  small  fluid  particles, 
and  are  carried  for  some  distance,  thus  causing  infection.  For  this 
reason  Mikulicz  recommended  his  mouth  protectors.  A  large  basin 
containing  a  lukewarm  antiseptic  solution  should  be  placed  near  the 
operator  and  his  assistants,  so  that  they  may  constantly  keep  their 
hands  disinfected,  even  though  they  do  not  come  in  contact  with 
unclean  objects  or  with  pus,  fseces,  urine,  etc. 

Sterilisation  of  Instruments. — The  instruments  are  best  disinfected 
by  boiling  them  for  live  to  ten  minutes  in  a  one-  to  two-per-cent.  solu- 
tion of  soda,  the  latter  substance  rendering  them  less  liable  to  rust  than 
plain  water.  Crystalline  soda  should  be  used  and  not  the  kind  adulter- 
ated with  sulphate  of  soda  or  common  salt.  In  order  to  prevent  the 
instruments  from  rusting,  Levai  recommends  the  addition  of  pui'e  one- 
quarter-per-cent.  caustic  soda  to  the  water  and  allows  them  to  lie 
in  this  weak  solution.  They  are  much  less  likely  to  rust  if  placed 
in  water  that  is  already  boiling,  as  the  carl)onic  acid  has  then  Ijeen 
expelled  in  great  part  from  the  water.  The  knives  and  needles  are 
placed  in  a  separate  compartment  in  order  that  their  edges  may  not 
be  injured  by  contact  with  the  other  instruments.  As  wooden  handles 
on  instruments  are  soon  damaged  by  boiling,  nickel-plated  metal 
handles  are  preferable. 

Instruments  are  not  sufficiently  disinfected  by  simply  placing  them 
in  carbolic  or  other  antiseptic  solution  (Gartner,  Kiimmel,  Gutsch, 
Redard,  Davidsohn).  A  sterilising  apparatus  for  instruments  can  be 
made  for  a  small  price  by  any  tinman,  in  the  following  manner :  a 
large  box  made  of  sheet  copper,  with  a  removable  top,  is  provided 


§6.] 


THE   PREPARATIONS  FOR  AN  ASEPTIC   OPERATION. 


13 


Fig.  15.- 


-Apparatus  for  boiling  instruments 
(Sclumnielbuschj. 


with  a  tray  of  tin  plate  which  is  punched  full  of  holes  ;  the  tray 
holds  the  instruments,  and  has  two  handles  attached  to  it  so  that  it  can 
'be  lifted  out  after  the  boiling  and  placed  in  a  three-per-cent.  solution  of 
carbolic  acid.  A  very  excellent  ap- 
paratus, devised  by  Schimmelbusch, 
is  illustrated  in  Fig.  15,  but  it  is 
much  more  expensive.  The  figure 
needs  no  explanation.  At  the  close 
of  the  process  of  sterilisation  the 
wire  tray  E^  which  holds  the  instru- 
ments, is  taken  out  and  placed  in 
three-per-cent.  carbolic  or  sterile  salt 
solution  contained  in  a  glass  dish  or 
tray  made  of  enamel-covered  metal. 

Before  using,  I  generally  Avipe 
off  every  knife  carefully  with  a  piece 
of  sterilised  cotton  moistened  in  a 
three-per-cent.  solution  of  carbolic 
acid.  This  is  a  mechanical  means 
of  disinfection  which  Gartner  has 
shown  to  be  particularly  efficacious. 
During  the  operation  the  instruments  should  lie  in  an  antiseptic  solu- 
tion, such  as  three-per-cent.  carbolic  acid,  one-half-  to  one- per-cent. 
creosol,  or  in  sterile  salt  solution,  or  one-  to  two -per-cent.  soda  solution, 
or  they  are  used  dry.  They  are  placed  in  trays  made  of  glass,  porce- 
lain, and  metal.  The  non-breakable  and  easily  cleaned  vessels  of 
enamelled  metal  which  are  used  in  the  kitchen  are  very  good  for  this 
purpose.  After  every  operation  the  instruments  are  scrubbed  with  a 
brush  and  soap  in  a  three-per-cent.  solution  of  carbolic  acid  and  then 
polished. 

Metallic  catheters  and  sounds  are  sterilised  like  all  metallic  instru- 
ments by  boilhig  them.  Soft  catheters  and  bougies  are  sterilised  by 
subjecting  them  to  steam  from  five  to  fifteen  minutes,  or  to  formalin, 
or  hydrochloric  acid  vapour.  They  may  also  be  sterilised  by  placing 
them  for  twenty-four  hours  in  a  three-per-cent.  solution  of  formalin 
in  glycerine,  and  then  kept  in  glycerine.  Catheters  taken  directly 
from  the  formalin  solution  must  first  be  dipped  before  using  in  a  non- 
irritating  solution,  such  as  glycerine.  Levai  places  the  bougies  and 
catheters  before  use  in  liquefied  paraffine,  which  has  a  strong  antiseptic 
action. 

Among  other  sterilising  apparatus,  those  of  Braatz,  Kronacher; 
Sternberg,  Mehler,  Klien,  and   Slomann  should  be  mentioned.     For 


14  THE  PREPARATIONS  FOR  AN   ASEPTIC   OPERATION. 

private  ])ractice  antl  military  surgery  Kronaclier,  Turner,  Lauten- 
scliliiger,  and  others  have  devised  transportable  apparatus. 

Sterilised  Gauze  Wipes. — For  sponging  the  wound  during  the  opera- 
tion, gauze,  or  cotton  balls  wrapped  in  gauze,  should  be  used.  These 
wipes  are  sterilised  by  placing  them  for  half  an  hour  in  the  steam  ster- 
iliser. They  are  decidedly  preferable  to  ordinary  sponges,  as  they  are 
only  used  once,  and  are  afterwards  burned.  A  large  stock  of  such 
gauze  wipes  can  be  always  kept  on  hand  in  a  bichloride  solution  (1  to 
1,000),  but  it  is  better  to  use  those  that  are  freshly  sterilised. 

Disinfection  of  Sponges. — Ordinary  sponges  very  quickly  become  use- 
less after  sterilisation  in  the  hot  steam  of  a  steriliser,  and  they  are  best 
disinfected  in  the  following  way :  After  pounding  them  thoroughly, 
rinse  them  in  a  solution  of  potassium  permanganate  (1  to  500-1,000), 
then  soak  them  for  a  quarter  of  an  hour  in  a  solution  consisting  of 
four  fifths  to  one  per  cent,  of  hyjDOsulphite  of  soda  and  from  one  fifth 
to  eight  per  cent,  of  pure  hydrochloric  acid  (Keller) ;  then  place  them 
for  a  quarter  of  an  hour  more  in  boiling  water  or  in  a  boiling  soda 
solution  of  a  strength  of  one  per  cent.  The  sponges  are  stored  in  a 
five-per-cent.  solution  of  carbolic  acid  or  one-tenth-per-cent.  solution 
of  bichloride  of  mercury. 

Sterilisation  of  Dressings,  Silk,  Catgut. — SOk,  catgut,  drainage  tubes, 
dressings,  and  bandages  should  also  be  rendered  perfectly  sterile.  Silk 
should  be  boiled  for  half  an  hour  in  a  bichloride  solution  (2  to  1,000) 
or  a  five-per-cent.  carbolic  solution,  and  the  other  materials  can  be 
treated  by  dry  sterilisation — i.  e.,  by  keeping  them  in  the  dry  steriliser 
for  half  an  hour  at  a  temperature  of  100°  to  130°  C  For  the  sterilisa- 
tion of  catgut,  see  page  94. 

The  Spray. — Some  years  ago  the  operation  and  the  application  of  the 
dressings  were  always  carried  out  under  the  Lister  spray — in  other  words,  in 
a  fine  mist  of  carbolic  acid.  The  management  of  the  hand  spray  can  be  un- 
derstood without  further  exjilanation  from  the  illustration  in  Fig.  1(3.  The 
steam  spray  apparatus  consists  of  a  vessel  containing  water,  with  a  spirit 
lamp  underneath.  The  boiler  is  filled  through  the  opening  at  a  and  then 
closed  by  a  stopper  which  is  screwed  in  place.  At  b  is  placed  a  safety  valve, 
which  allows  the  steam  collected  in  the  kettle  to  escape  in  case  the  cock  at  c 
is  turned  oil.  The  steam  passes  from  the  boiler  through  a  tube  closed  and 
opened  by  the  cock  c,  then  into  a  glass  containing  three  to  five  per  cent,  car- 
bolic acid,  and  drives  the  latter  out  of  the  end  of  the  tube  in  the  form  of  a 
spray,  the  dii'ection  of  which  can  be  changed  by  means  of  the  handle  d. 

At  present  the  spray,  as  has  been  said,  is  seldom  employed,  and  I,  j)erson- 
ally,  never  use  it.  It  has  been  proved  that  the  results  obtained  without  the 
spray  are  just  as  good  as  those  obtained  with  it.  The  spray  is  troublesome, 
inconvenient  for  the  operator,  and  not  free  from  danger  to  the  patient  on 
account  of  the  not  unimpoi'tant  chilling  it  may  cause,  and  from  the  danger 


§6.] 


THE   PREPAEATIONS  FOR  AN  ASEPTIC   OPERATION. 


15 


of  carbolic  or  bichloride  poisoning.  I  sometimes  use  the  spray  before  a  lapa- 
x'otomy  when  I  wish  to  purify  the  air  of  the  operating  room,  and  for  this 
purpose  I  use  a  steam  spray  placed  as 

high  up  as   possible.      In    hospitals  h  _^      d 

fitted  with  steam  or  water  pipes,  a  Or- 


FiG.  16. — Hand  spraying  apparatus 


Fig.  17. — Steim  «},i  iMntr   i}  [  n  ltu■^ 


very  efPective  spray  apparatus  can  be  contrived  by  connecting  the  steam  pipe 
with  the  boiler  of  the  apparatus,  and  in  this  way  the  air  in  the  operating 
room  can  be  very  easily  and  cheaply  rendered  germ  free — in  other  words, 
disinfected.  This  should  be  done  after  a  clinic,  for  example,  when  ah  opera- 
tion such  as  a  laparotomy  is  to  be  performed  in  the  same  room.  Removal 
of  the  dust  in  the  operating  room  and  wards  by  means 
of  steam  is  very  desirable,  as  the  dust  in  these  places 
contains  microbes,  which  can  give  rise  to  infection. 

Otherwise  disinfection  of  the  air  of  the  operating  ~X7~ 
room  is  not  necessary,  since,  in  general,  wounds  are  only 
infected  by  contact  with  the  microbes  on  unclean  and 
insufiiciently  disinfected  hands,  dressings,  and  instru- 
ments, but  not  by  the  bacteria  in  the  air  (Kiimmel,  P.  Fiir- 
bringer),  provided  the  room  is  free  from  dust.  I  lay  great 
stress  upon  covering  the  neighbourhood  of  the  field  of 
operation  with  sterilised  towels  dipped  in  a  one-tenth-per- 
cent, solution  of  bichloride  of  mercurv. 


Preparation  of  the  Dressings. — I  sLould  mention 
that  the  aseptic  coverings  of  the  wounds,  dressings, 
bandages,  etc. — sterilised  by  heating  them  at  a  tem- 
perature of  100°  to  130°  C. — are  made  ready  in  ad- 
vance. We  shall  speak  of  these  in  Chapter  II.  (The 
Technique  of  applying  Dressings). 


Luj 


Fig.  is. — Metallic  or 
hard-rubber  case 
with  spool  for 
aseptic  catgut  and 
silk. 


Preparations  for  Operations  in  Private  Practice.— If 

an  operation  is  to  be  conducted  aseptically  outside  of  a 
clinic  or  hospital,  as  large  and  light  a  room  as  possible  should  be  selected, 
and  thoroughly  cleaned  and  aired.     The  surest  and  simplest  ways  of  disin- 
fecting a  room  are  to  rub  down  the  walls  and  ceiling  with  bread  (E.  von 


16  THE   PREPARATIONS   FOR  AN  ASEPTIC   OPERATION. 

Esniarch),  or  to  generate  foruaaliii  vapour  in  Schering's  apparatus,  or  to  burn 
sulphur  after  closing  off  the  room  thoroughly.  A  table,  on  which  to  place 
the  patient,  should  be  provided,  and  covered  with  some  water-tight  material 
and  then  with  sterilised  linen;  and  two  or  three  other  tables  should  be  near 
by,  likewise  covered  with  sterilised  linen,  to  hold  the  instruments,  dressings, 
and  wash-basijis. 

Several  wash-basins,  soap,  absolute  alcohol,  bi'ushes,  towels,  sterilised 
dishes  for  the  instruments,  and  sponges  should  be  within  reach,  as  well  as 
warm  sterilised  water  in  large  quantities,  chloroform  or  ether,  concentrated 
carbolic  solution,  tablets  of  bichloride,  aseptic  sjjonges  or  gauze  pads,  drains, 
silk,  catgut,  and  the  necessary  instruments  sterilised  by  boiling  in  a  one-per- 
cent, soda  solution,  and  dressings  and  bandages. 

Silk  and  catgut  can  be  carried  about  very  easily  in  the  simple  apparatus 
pictured  in  Fig.  18. 


CHAPTEK  II. 

THE    ALLEVIATION    OF    PAIN    DURING    OPERATIONS. GENERAL    AND    LOCAL 

ANAESTHESIA. 

History. — Chloroform. — The  physiological  action  and  the  method  of  administering 
chloroform. — Symptomatology  of  chloroform  narcosis. — The  possible  accidents 
during  chloroform  narcosis  :  death  from  chloroform. — Treatment  of  the  possible 
accidents  during  chloroform  narcosis. — Other  ansBsthetics  :  methyl  compounds. — 
Ether. — The  phenomena  of  ether  narcosis. — Method  of  administering  ether. — The 
remaining  ether  compounds. — Nitrous  oxide  (laughing  gas)  as  an  anfesthetic. — 
Other  anaesthetics. — Mixed  narcosis. — Local  anaesthesia. 

§  7.  The  Alleviation  of  Pain  during  the  Operation. — A  distinction  is 
made  between  general  angesthesia — i.  e.,  narcosis  which  is  caused  by 
the  inhalation  of  some  sleep-producing  vapour  or  gas — and  the  local 
anaesthesia  which  is  limited  to  a  particular  portion  of  the  body,  and 
produced  by  the  local  application  of  a  substance  to  the  part  of  the 
body  to  be  operated  upon. 

Historical. — Since  the  earliest  times  attempts  have  been  made  to  perform 
opei'ations  with  the  aid  of  some  means  for  allaying  pain,  but  the  methods 
were  invariably  bad,  and  the  action  of  the  remedies  which  were  tried  was 
insufficient.  It  was  not  till  the  year  1846,  with  the  introduction  of  ether  as 
an  anaesthetic,  that  the  dream  of  the  old  surgeons  was  to  come  true — namely, 
the  performance  of  even  major  operations  without  pain. 

As  early  as  the  year  1800,  Humphry  Davy,  reasoning  from  his  numer- 
ous physiological  experiments,  had  recommended  nitrous  oxide  (laughing 
gas)  as  an  ansesthetic  ;  and  Horace  Wells,  a  dentist  in  Hartford,  tested  the 
remedy  in  1844  by  extracting  twelve  or  fifteen  teeth  ;  but  he  was  not  able  to 
introduce  the  drug  as  an  anaesthetic  into  general  surgical  practice. 

In  ancient  times  cannabis  indica  and  opium  were  the  chief  drugs  for 
controlling  pain.  Besides  these,  the  pulverised  stone  of  Memphis  was  used— 
a  kind  of  marble  which,  when  treated  with  acetic  acid,  gives  off  carbonic  acid 
and  in  this  way  produces  a  certain  amount  of  local  aneesthesia.  Mandrake 
root,  made  into  a  decoction  with  wine,  was  also  given  internally,  and  was 
used  especially  by  the  ancient  Greek  physicians,  and  in  fact  was  employed 
during  the  middle  ages  till  the  end  of  the  sixteenth  century.  In  the  middle 
ages  patients  were  often  made  to  inhale  vapours  made  from  hemlock  and 
from  the  juice  of  the  mandrake  leaf.  Of  interest  in  this  connection  are  the 
experiments  of  Theodoric  of  Cervia,  a  learned  Dominican,  who  at  his  death, 
in  1298,  was  Bishop  of  Bologna.  A  celebrated  surgeon  of  Salerno,  Mazzeo 
3  17 


18  THE  ALLEVIATION  OF   PAIN  DURING  OPERATIONS. 

del  la  Moutagna  (1309-1349),  is  said  to  have  given  the  patients  whom  he  was 
about  to  operate  upon  some  sleep-producing  potion.  Porta  also  speaks  of  a 
remedy,  without  describing  it  more  exactly,  which,  when  inhaled,  brought 
on  a  deep  sleep. 

Besides  these  methods,  excessive  bloodletting  till  fainting  occurred,  com- 
pression of  the  vessels  and  nerves  (Moore),  enormous  doses  of  tartar  emetic, 
electricity,  animal  magnetism,  and  hypnotism  have  all  been  tried.  On 
April  8,  1829,  Cloquet  is  said  to  have  removed  without  pain  a  cancer  of  the 
breast,  together  with  the  axillary  glands,  from  a  fourteen-year-old  girl  dur- 
ing the  magnetic  sleep,  and  in  1842  Ward  amputated  a  thigh  under  the  same 
conditions.  Guerineau  also  performed  a  painless  amputation  of  the  leg 
while  the  patient  was  in  the  hypnotic  slumber. 

Many  other  attempts  were  made  to  perform  operations  painlessly  during 
the  hypnotic  state,  but  they  were  seldom  successful.  In  hysteria  or  other 
pathological  conditions  of  the  nervous  system  liypnotic  anaesthesia  is  more 
easily  brought  about.  It  is  well  known  that  hypnotism  has  of  late  attained 
a  growing  importance  for  diagnostic  purposes  and  as  a  therapeutic  measure. 
It  can  at  times  be  advantageously  used  on  surgical  patients. 

Two  Americans — the  chemist  Charles  Jackson  and  the  dentist 
AY.  L.  Ct.  Morton — introduced  ether  as  an  anaesthetic  into  general  sur- 
s;ica.l  use,  after  the  inhalation  of  ether  had  already  been  used  bv  others 
to  allay  pain  and  the  physiological  action  of  the  vapour  was  known. 
Furthermore,  in  1842  and  1813,  W.  C.  Lang,  a  physician  in  Athens, 
had  anaesthetised  several  patients  \vith  ether  without  publishing  his  ob- 
servations. Morton  induced  Warren,  the  surgeon  of  the  Massachusetts 
Hospital,  to  try  the  new  remedy,  and  the  latter,  on  October  IT,  181(), 
removed  without  pain  a  tumour  of  the  neck  under  ether  narcosis.  The 
knowledge  of  the  new  discovery  spread  quickly  to  Europe,  first  to 
England,  then  to  France,  Germany,  and  the  other  countries.  In  Eng- 
land, Robinson,  Liston,  and  Simpson  were  the  first  to  try  it,  and  they 
were  followed  by  Malgaigne  in  France.  Schuh  was  the  first  in  Ger- 
many, and  on  January  27,  1817,  he  removed,  without  pain,  a  telan- 
geiectasis  under  ether. 

But  the  supremacy  of  ether  as  an  anaesthetic  was  not  to  continue 
long.  In  November,  1817,  Simpson,  as  a  result  of  some  eighty  obser- 
vations, including  surgical  and  labour  cases,  recommended  chloroform, 
which  had  already  been  discovered  in  1831  by  Soubeiran,  in  Paris,  and 
had  lain  unnoticed  on  the  apothecary's  shelves  for  sixteen  years. 
Ether  was  very  quickly  superseded  by  chloroform,  and  the  enthusiasm 
for  the  new  remedy  was  tremendous.  But  soon  the  first  deaths  from 
chloroform  were  reported,  and  the  wish  for  a  new  anaesthetic  became 
active.  Numerous  other  drugs  were  tried,  but  at  the  present  day 
chloroform  and  ether  hold  the  field  in  triumph  without  rivals  worthy 
of  the  name.     In  recent  times  ether  has  again  gained  ground,  and  is 


§8.]  CHLOROFORM  NARCOSIS.  19 

used  especially  in  America,  in  Lyons,  and  lately  also  in  England,  in 
Switzeriand,  and  in  Germany.  I  use  ether  a  great  deal,  particularly 
if  the  respiratory  passages  and  the  lungs  are  sound,  and  I  am  well 
satisfied  with  it.  Both  drugs,  we  shall  see,  have  their  advantages  and 
disadvantages,  and  we  can  not  get  along  without  either  of  them.  In 
my  opinion  ether  should  be  used  when  the  heart  is  diseased,  and  chlo- 
roform is  preferable  in  cases  with  a  pulmonary  lesion.  Ether  is  also 
to  be  preferred  to  chloroform  in  case  of  disease  of  the  liver  and  kidney, 
as  the  latter  is  more  likely  to  give  rise  to  serious  degeneration  of  these 
organs.  Of  the  other  anaesthetics,  nitrous  oxide,  or  langhing  gas,  and 
bromethyl  are  most  used,  chiefly  for  short  operations  and  by  dentists. 
We  shall  first  take  up  chloroform. 

§  8.  Chloroform  Narcosis.  The  Chemical  Eeactions  of  Chloroform.— 
Trichlormethan  (CHCI3)  is  a  clear,  colourless,  very  volatile  liquid,  with  a 
pleasant,  aromatic  odour,  and  a  sweet  and  afterwards  burning-  taste.  It  can 
be  mixed  with  ether  and  alcohol  in  all  proportions,  and  is  soluble  in  two 
hundred  parts  of  water.  Chloroform  is  very  slightly  inflammable,  and  has 
at  15°  C.  (55°  F.)  a  specific  gravity  of  1.502.  It  is  decomposed  by  daylight 
into  hydrochloric  acid,  chlorine,  and  free  formic  acid,  and  is  therefore  to  be 
kept  in  the  dark,  preferably  in  glass  bottles  which  are  covered  with  paste- 
board. By  the  addition  of  one  half  to  one  per  cent,  absolute  alcohol  the 
decomposition  of  chloroform  can  be  prevented. 

Only  such  chloroform  should  be  used  as  has  been  previously  proved  to  be 
pure.  The  impurities  of  chloroform  consist  in  adulterations  with  spirits  of 
wine,  ether,  etc.,  in  the  very  dangerous  compounds  of  methyl  formed  during 
its  preparation,  and  finally  in  the  decomposition  products  which  develop  if 
the  drug  is  long  exposed  to  the  action  of  light  and  air  (free  chlorine,  com- 
pounds of  the  hydrocarbons  with  chlorine,  aldehyde,  hydrochloric  acid,  acetic 
acid,  and  formic  acid).  The  testing  of  chloroform  is  a  chemical  procedure, 
which  must  be  done  by  the  chemist  or  the  apothecary ;  but  the  surgeon  should 
always  make  Hepp's  smelling  test,  which  is  as  simple  as  it  is  useful.  Chem- 
ically pure  Swedish  filter  paper  is  dipped  in  chloroform,  the  latter  allowed  to 
evaporate,  and  the  dry  paper  smelted  of.  If  the  chloroform  is  pure  the 
paper  has  no  odour  ;  but  if  there  is  a  peculiarly  sharp  and  irritating  odour 
the  chloroform  is  impure,  and  it  is  either  acid  from  decomposition  or  it  con- 
tains the  chlorine  substitution  products  of  the  ethyl  or  methyl  series.  Chlo- 
roform can  also  be  tested  chemically  by  distillation  over  crude  potash  at  a 
temperature  of  60°  to  61°  C.  (140°  to  142°  F.).  The  chloroform  prepared  from 
salicvlide  chloroform  (Anschutz)  is  a  perfectly  pure  form  and  can  be  recom- 
mended very  heartily.  The  production  of  anaesthesia  requires  a  somewhat 
longer  time  than  in  the  case  of  the  ordinary  chloroform  (usually  from  ten  to 
twenty  minutes),  but  the  patient  takes  it  well  and  unpleasant  sequete  are 
very  rare.  Chloroform  medicans  (Pictet),  purified  by  crystallization,  is  also 
an  excellent  preparation. 

Physiological  Action  of  Chloroform.— By  inhalation,  chloroform  vapour  is 
carried  to  the  lungs,  or  more  particularly  to  the  blood,  and  probably  circu- 


20  THE   ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

lates  in  the  blood  in  chemical  combination  with  the  haemoglobin  of  the  red 
blood-corpuscles.  Cliloroform  has  the  power  in  part  of  directly  destroying 
the  red  blood-corpuscles,  and  in  part  of  robbing  them  of  their  ability  to  take 
up  oxygen  and  to  drive  out  carbonic  acid  (.Bottciier,  Schmiedeberg,  and 
others).  The  icterus — i.  e.,  htematogenous  icterus — vvhich  Nothnagel  ob- 
served in  animals  is  probably  due  to  the  power  possessed  by  chloroform  and 
ether  of  destroying  the  red  blood-corpuscles. 

The  destruction  of  the  red  blood-corpuscles  is  preceded  by  a  change  in 
their  form.  Thej"  become  spherical,  and  these  spheres  partially  dissolve  in 
the  blood  plasma,  leaving  behind  small  granules.  Chloroform  also  combines 
intimately  with  the  fixed  tissue  cells.  It  can  thei-efore  remain  in  the  body 
for  a  longer  or  shorter  time,  depending  upon  the  closeness  of  its  combination 
with  tbe  cells.  The  blood  is  only  the  means,  probably,  of  carrying  the 
chloroform,  and  the  chief  cause  of  the  anaesthesia  is  to  be  sought  in  the  cer- 
tain but  not  yet  fully  understood  changes  in  the  central  nervous  system.  It 
is  certain,  however,  that  these  changes  do  not  depend  upon  disturbances  of 
the  circulation,  such  as  hyperaemia  or  anaemia  of  the  nerve  centres.  Accord- 
ing to  Luthei*,  the  physiological  aud  pathological  action  of  chloroform  de- 
pend chiefly  upon  its  power  of  dissolving  lecithin  and  cholesterin  ;  the  fatty 
degeneration  produced  in  the  kidney,  liver,  heart,  muscles,  etc.,  is  to  be 
regarded  as  a  coagulation  necrosis,  and  chemically  as  a  lecithin  degenera- 
tion of  the  cell  protoplasm. 

The  drug  is  carried  to  all  the  organs  by  the  blood  as  it  circulates,  includ- 
ing the  central  nei-vous  system,  the  brain,  and  the  spinal  cord.  The  ganglion 
cells  are  chiefly  affected,  while  the  nerve  flbres  suffer  no  loss  of  function,  but 
retain  their  normal  excitability  (Bernstein).  The  sensory  ganglion  cells  are 
first  attacked  by  the  poison,  then  the  motor,  as  is  evident  from  the  final  pa- 
ralysis of  the  automatic  movements  of  the  heart  and  respiration  in  a  fatally 
ending  narcosis.  According  to  Flourens,  the  paralysis  of  the  nei*ve  centres 
begins  in  the  great  lobes  of  the  brain ;  it  then  attacks  the  cerebellum,  and 
finally  the  spinal  cord,  where  first  sensation  and  then  motion  are  lost.  The 
medulla  oblongata  retains  its  function  the  longest,  then  it  also  loses  its  ac- 
tivity, and  life  comes  to  an  end.  The  loss  of  sensation  and  of  the  sense  of 
pain  is  first  noticeable  in  the  back  aud  extremities,  and  last  in  the  cornea 
with  its  rich  nerve  supply. 

The  changes  in  the  blood  pressure  and  the  action  of  the  heart  have  been 
carefully  studied  by  Lenz,  Scheinesson,  Koch,  Bowditch,  Minot,  and  others. 
Chloroform  -acts  upon  the  vaso-motor  centre,  and  also,  in  all  probability, 
directly  upon  the  heart  muscle  and  its  ganglia.  The  arterial  tension  is  re- 
duced, the  blood  pressure  sinks,  the  energy  of  the  heart's  action  is  diminished, 
and  the  rapidity  of  the  circulation  is  lessened.  The  blood  of  the  whole  body 
becomes  more  or  Jess  venous,  and  a  decrease  in  oxidation  with  a  sinking  of 
the  temperature  of  the  body  takes  place  as  a  result  of  the  diminished  heat 
production. 

Respiration  is  infiuenced  in  two  ways  by  chloroform  :  in  the  first  place, 
the  direct  action  of  the  chloroform  upon  the  terminal  branches  of  the  fifth 
nerve  in  the  mucous  membrane  of  the  nose  may  cause  a  temporary-  reflex 
cessation  of  breathing,  and  a  noticeable  slowing  of  the  heart  (stimulation  of 
the  vagus),  particularly  at  the  outset  of  the  narcosis.     In  the  second  place, 


§8.]  CHLOEOFORM  NARCOSIS.  21 

chloroform  acts  directly  upon  the  respiratory  centre,  and  the  changes  thus 
brought  about  in  respiration  are  independent  of  the  changes  in  the  circula- 
tion. The  centre  for  breathing  is  first  stimulated  by  chloroform,  and  later 
depressed,  causing  the  breathing  to  become  slower  and  more  shallow. 

The  behaviour  of  the  pupils  is  of  very  great  importance.  The  dilatation 
of  the  pupils  occurring  at  the  outset  of  the  narcosis  is  dependent  upon  the 
mental  excitement  of  the  patient  and  upon  the  reflex  stimulation  of  the  fibres 
of  the  sympathetic  nerve  governing  the  opening  of  the  ins,  brought  about  by 
the  irritation  of  the  branches  of  the  trigeminal  nerve  in  the  naso-lachrymal 
duct.  All  these  irritations  which  dilate  the  pupil  cease  when  sleep  or  nar- 
cosis takes  place,  and  the  pupil  is  therefore  contracted. 

The  utei'ine  contractions  during  childbirth  are  not  stopped  during  chloro- 
form narcosis.  The  influence  of  the  drug  upon  the  muscular  fibres  of  the 
intestine  is  not  known.  Chloroform  produces  a  complete  relaxation  of  the 
voluntary  muscles.  It  is  important  to  remember  that  chloroform  is  excreted 
in  the  milk  of  nursing  women,  and  may  be  found  in  the  blood  of  the  foetus. 

Chloroform  is  excreted,  according  to  Zeller,  chiefly  in  the  form  of  chlorides 
in  the  urine,  and  only  about  a  third  is  excreted  as  unchanged  chloroform  by 
the  lungs  and  kidneys.  The  excretion  of  the  chlorine  derived  from  the 
breaking  up  of  the  chloroform  in  the  system  is  just  as  slow  as  the  excretion 
of  iodine  after  the  external  application  of  iodoform. 

Unchanged  chloroform  can  be  found  in  the  urine  of  a  patient  who  has 
been  chloroformed,  and  if  the  urine  is  boiled  with  Fehling's  solution  the 
latter  will  be  immediately  reduced  to  the  black  copper  oxide,  and  not  the  red 
(Hegar-Kaltenbach,  C.  Theim,  P.  Fischer).  As  a  result  of  the  destruction  of 
the  red  blood-cells  by  the  action  of  chloroform,  haemoglobinuria  occasionally 
occurs,  though  bilirubinuria  is  more  common,  for  the  reason  that,  owing  to 
the  destruction  of  the  red  blood-cells,  an  increased  formation  of  bile  colouring 
matter  takes  place,  which  is  excreted  in  the  urine.  Nothnagel  found  biliary 
pigment  in  the  urine  of  animals,  while  in  man  jaundice  and  bile  pigment  in 
the  urine  are  rarer.  The  urine  sometimes  contains  casts  and  albumen,  more 
rarely  sugar.  Some  authorities,  including  Frankel.  Wunderlich,  and  Ziegler, 
claim  that  transient  albuminuria  with  casts  is  more  common  after  the  use  of 
chloroform  than  of  ether.  A  transient  albuminuria  occurs,  according  to 
Ajello,  in  eighty  per  cent,  and  according  to  Zachrisson  in  38.06  to  44.45  per 
cent,  of  the  cases  of  chloroform  angesthesia ;  while  in  the  mixed  chloroform- 
ether  anaesthesia  the  percentage  is  16.59  to  20.77.  Rindskopf  found  that 
among  ninety -three  cases  where  chloroform  had  been  used  thirty-one  showed 
pathological  elements  in  the  urine  (albumen,  casts,  leucocytes,  epithelium 
from  different  sources,  and  erythrocytes).  The  urine  is  usually  normal 
again  at  the  end  of  two  or  three  days,  but  the  experiments  of  Babacci  and 
Bebi  show  that  the  nephritis  resulting  from  chlorofoi'm  is  more  likely  to 
take  on  a  chronic  chai'acter  than  the  nephritis  following  the  use  of  ether. 
Thomson  and  Kemp,  on  the  other  hand,  claim  that  ether  is  more  harmful  to 
the  kidneys  than  chloroform.  Nachod  found  in  the  urine  of  children,  acetone 
and  diacetic  acid,  both  separately  and  in  combination  with  one  another. 
Kast  and  Mester  found  in  the  urine  of  patients  who  had  died  from  the  effects 
of  a  long-continued  anaesthesia,  a  substance  containing  sulphur  and  resem- 
bling cystin.     It  follows  from  what  has  been  said  that  the  kidneys  are  more 


22  THE   ALLEVIATION   OF   PAIN   DURING   OPf:RATIONS. 

or  less  damaged  by  the  use  of  chloroform  and  that  consequently  it  should  be 
employed  with  caution.  A  patient  should,  for  example,  never  be  chloro- 
formed a  number  of  times  within  a  few  days. 

§  9.  Method  of  Administering  Chloroform. — If  it  lias  been  decided 
to  narcotise  a  patient  for  an  operation,  certain  precautionary  measures 
are  to  he  observed.  His  general  condition  must  be  determined  by  a 
careful  examination  of  the  internal  organs,  especially  the  heart  and 
lungs.  In  cases  of  extensive  j^ulmonary  disease,  of  pleurisy  with 
effusion,  of  heart  disease,  particularly  valvular  insuificiency  and  fatty 
heart,  of  atlieromatous  degeneration  of  the  arteries,  of  alcoliolisra,  of 
great  weakness  from  loss  of  blood,  of  nephritis,  diabetes,  epilepsy, 
many  diseases  of  the  brain,  etc.,  one  must  be  very  careful  in  the  use 
of  ana?sthetics,  and  one  must  decide  in  each  case  whether  the  nai'cosis 
is  justifiable.  In  diseases  of  the  heart  ether  should  always  be  used  in 
preference  to  chloroform. 

If  possible,  the  patient's  stomach  should  be  empty,  since  otherwise 
the  vomiting,  which  so  easily  occurs,  "will  disturb  the  quiet  progress  of 
the  narcosis  and  of  the  operation ;  moreover,  the  movements  of  the 
diaphragm  duriug  the  narcosis  are  interfered  with  when  the  stomach 
is  distended.  Therefore,  without  exception,  patients  should  be  for- 
bidden to  take  solid  food  for  from  three  to  four  hours  before  the  opera- 
tion. In  England  and  America  it  is  customary  to  give  stimulants, 
especially  to  weak  patients,  before  the  narcosis.  Poncel  gives  repeated 
hypodermic  injections  before,  during,  and  after  chloroform  anaesthesia 
of  four  cubic  centimetres  of  diluted  cognac  at  a  temperature  of  38°  C. 
(one  part  cognac  to  two  parts  water).  The  administration  of  alcohol 
in  some  form  by  mouth  before  beginning  the  anaesthetic  is  simpler, 
and  is  particularly  desirable  in  tlie  case  of  alcoholic  patients.  For 
a  description  of  morphine- chloroform  anaesthesia  and  oxysparteine- 
morphine-chloroform  anaesthesia,  the  reader  is  refei-red  to  page  46. 
I  shall  merely  mention  here  that  I  always  inject  morphine  ten  to  twenty 
minutes  before  beginning  the  chloroform  or  ether  in  adults.  In 
many  operations,  particularly  those  in  the  peritoneal  cavity  and  about 
the  region  of  the  anus,  etc.,  the  intestine  should  be  previously  emptied 
by  a  laxative  or  enema. 

The  patient  should  be  clothed  as  lightly  as  possible,  -with  no  con- 
striction in  the  region  of  the  neck,  thorax,  or  abdomen  which  interferes 
"svith  respiration,  and  the  thorax  should  be  uncovered  so  that  the  respir- 
atory movements  can  be  watched.  Care  must  be  taken  not  to  allow 
the  patient  to  become  chilled,  as  marked  lowering  of  the  blood  pressure 
with  fatal  collapse  may  result.  For  the  same  reason,  the  operating 
room  must  be  kept  moderately  warm.     Too  high  a  temperature  in  the 


§9.]  METHOD  OF   ADMINISTERING  CHLOROFORM.  23 

room  is  to  be  avoided,  as  it  likewise  causes  a  lowering  of  the  blood 
pressure  (Allen).  In  suitable  cases,  operating  tables  that  can  be  heated 
are  used  (see  page  7).  False  teeth  and  plates  must  be  removed  from 
the  mouth.  In  order  to  diminish  the  dangerous  reflex  action  of  the 
heart,  produced  through  the  branches  of  the  trigeminal  nerve  -svithin 
the  nose,  Guerin  has  advised  that  the  nostrils  be  closed  with  cotton, 
some  form  of  clamp,  or  the  fingers,  so  that  the  patient  breathes  only 
through  the  mouth.  To  accomplish  the  same  purpose,  Rosenberg 
recommends  cocainisation  of  the  interior  of  the  nose  bj  means  of  a 
spray.  He  uses  0.02  of  a  ten-per-cent.  solution,  and  three  minutes 
later  0.01  in  each  nostril.  If  the  anaesthesia  has  to  be  much  prolonged 
he  repeats  the  cocainisation  every  half  hour.  Gerster  tested  this  pro- 
cedure in  one  hundred  cases,  and  found  it  efficient  except  in  alcoholic 
patients.  During  the  stage  of  excitement,  in  the  first  part  of  the  nar- 
cosis, I  fasten  the  patient  to  the  operating  table  by  means  of  a  leather 
strap  passed  over  the  thighs.  The  horizontal  position  is  usually  em- 
ployed, "with  the  head  slightly  raised. 

In  giving  ether,  the  patient's  head  should  be  inclined  somewhat 
backward  or  downward,  to  prevent  the  mucus  that  collects  in  the 
mouth  and  throat  from  being  aspirated  into  the  lungs,  causing  pneu- 
monia. In  operations  on  the  face,  in  the  mouth,  throat,  or  nose,  the 
blood  is  prevented  from  entering  the  trachea  by  using  the  morphine- 
chloroform  anaesthesia  (see  page  45,  Mixed  jS[arcosis),  or  by  operating 
with  the  patient  sitting  up  with  the  head  held  forward,  or  lyino- 
down  with  the  head  hanging  back  over  the  edge  of  the  table.  In  oper- 
ating on  the  patient  in  a  sitting  posture,  one  must  guard  against  fatal 
syncope  from  cerebral  anaemia. 

If  the  operation  must  be  performed  with  the  patient  lying  upon  his 
abdomen  or  side,  it  will  be  necessary  to  watch  the  res23iration  and 
heart  action  with  great  care.  In  order  to  have  good  control  over  the 
narcosis,  and  in  case  of  accidents,  one  should  never  administer  chloro- 
form without  the  presence  of  an  assistant ;  in  case  death  should  occur 
from  chloroform,  as  well  as  for  other  reasons,  it  is  well  to  have  a  wit- 
ness present. 

When  the  narcosis  is  to  begin  the  patient  should  be  quieted  by  a 
few  words.  It  is  important  that  the  patient's  surroundings  should  be 
quiet,  and  any  excitement  on  his  part  is  to  be  avoided.  For  this  reason 
he  should  be  spared  as  far  as  possible  the  shock  of  seeing  the  instru- 
ments and  other  preparations  for  the  operation.  While  inhaling  the 
chloroform  he  should  be  made  to  count  out  loud  slowly,  in  order  that 
the  breathing  may  be  regular  and  the  gradual  effect  of  the  chloroform 
may  be  watched. 


24 


THE   ALLEVIATION   OP   PAIN   DURING    OPERATIONS. 


Chloroform  may  be  administered  in  case  of  emergency  by  pouring 
it  upon  a  sponge  or  a  folded  cloth  placed  over  the  face.     It  is  better, 

however,  to  use  a  special 
mask,  such  as  the  one 
shown  in  Fig.  19.  This 
consists  of  a  wire  frame 
covered  with  porous 
woollen  cloth  or  thin 
flannel. 

Lately   I  have  been 

19.— Esmarch  method  of  administering  chloroform.         Iismg  the  excellent  chlo- 

roform    mask   which    I 

saw  used  in  Kocher's  clinic.    The  wire  frame,  which  is  easily  sterilised,. 

is  made  of  two  pieces,  A  and  B  (Fig.  30),  which  fold  together  on 

a  hinge,  inclosing 

between  them   a 

piece  of  compress 

which    has    been 

previously  spread 

out  on  the  frame 

A.      Rosenberg 

has      devised      a 

chloroform  mask 

with  a  graduated 

bottle     attached. 

Masks    made    of 

glass,  which  allow  the  anaesthetist  to  watch 

the  patient's  face,  have  also  been  employed.  In  administering  chloro- 
form, care  must  be  taken 
not  to  allow  the  patient  to 
inhale  the  vapour  in  too 
concentrated  a  form,  but 
to  permit  a  suitable  ad- 
mixture with  atmospheric 
air.  For  this  reason  the 
chloroform  should  not  be 
poured  on  the  mask  too 
abundantly,  and  the  mask 
should  not  be  pi'cssed 
down  too  tightly  over  the 
face.  It  should  be  ad- 
ministered in  drops,  but 


Fig.  20. — Chloroform  mask. 


Fig.  21. — Chloroform  mask. 


'•] 


METHOD   OF  ADMINISTERING  CHLOROFORM. 


25 


continuously.  For  this  purpose  the  dropper  shown  in  Fig.  22  may  be 
attached  to  any  bottle.  If  the  chloroform  is  poured  out  too  freely  it 
not  infrequently  runs   on  to  the  ^.-r 

neck  and  chest,  and  can  cause  a  ,.--""      <,^ 

very  troublesome  erythema  or 
burn.  So  it  is  best  to  lay  a  light 
compress  on  the  neck  of  the  pa- 
tient, and  to  place  a  piece  of  cot- 
ton or  a  small  sponge  on  the  inner 
surface  of  the  cloth  which  covers 
the  apparatus,- 

Several  forms  of  apparatus 
have  been  devised  for  mixing  the 
chloroform  vapour  with  a  known 
proportion  of  air,  a  matter  which 
is  of  great  importance  (Bert,  Kro- 
necker,  Pean,  Thiriar,  Kappeler). 

One  of  the  best  of  these  is  Junker's  (Fig.  23),  the  description  of  which 
is  as  follows  : 


Fig.  22. — Chloroform-dropper  consisting  of  the 
capillary  tube  a,  with"  silver  wire  d^  the 
small  tube  J  admitting  air,  and  the  cork,  c. 


The  Chloroform  Apparatus  of  Junker  and  Kappeler.— The  flask  F  is  filled 
to  about  cue  third  with  chloroform,  and  is  fastened  by  a  hook  to  a  button- 
hole on  the  chloroformer's  coat.  By  pressing  the  rubber  bulb  B  a  mixture 
of  chloroform  and  air  is  supplied  to  the  patient.  The  mouthpiece  which  the 
patient  wears  is  connected  with  the  flask  jF  by  a  rubber  tube,  and  is  made 
of  hard  rubber  or  nickel-plated  metal,  with  incisures  to  fit  the  nose  and  chin, 

over  each  of  which  there 
is  a  valve  to  allow  for 
expiration,  and  two  other 
valves  which  can  be  closed 
or  opened  to  admit  •  air, 
thus  permitting  the  chlo- 
roform-air mixture  to  be 
further  diluted.  Both  of 
the  latter  valves  are  placed 
at  the  junction  of  the 
mouthpiece  with  the  tube 
from  the  flask  F.  The  ex- 
piratory valve  is  situated 
in  the  other  and  smaller 
of  the  attachments  to  the  mouthpiece.  Kappeler  has  lately  modified  the 
Junker  apparatus  so  as  to  allow  the  chloroform  to  be  mixed  with  air  in 
a  definite  proportion.  He  recommends  the  proportion  of  10.17  grammes  of 
chloroform  to  100  litres  of  air  (see  page  36).  Wiskemann's  apparatus  like- 
wise makes  it  possible  to  administer  chloroform  in  a  definite  amount  and 
proportion. 


Fig.  23. — Junker's  apparatus  for  administering  chloroform. 


26 


THE  ALLEVIATIOX  OF   PAIX   DURIXG   OPERATIONS. 


Suitable  instruments  should  be  ready,  in  case  at  any  time  during 
the  narcosis  it"  may  be  necessary  to  forcibly  open  the  mouth  and  pull 
forward  the  tongue,  which  may  have  fallen  back  and  plugged  the 
pharynx.  A  wedge-shaped  piece  of  wood  is  the  simplest  instrument 
for  forcibly  opening  the  mouth,  though  Heister  and  Roser  have  devised 
special  instruments  for  this  purpose.  Heister' s  is  rejiresented  as  open 
in  Fig.  24.  By  turning  the  thumb-screw  and  separating  the  two  bars 
which  lie  in  contact  when  the  instrument  is  closed,  the  jaws  are  forced 
apart.     Roser's  mouth-gag  is  illustrated  in  Fig.  25  as  it  appears  when 


Fig.  2-1. — Heister's  moutli 
speculum. 


Fig.  25. — Eoser's  mouth-o-asr. 


20. — Forceps  for  drawing 
the  tontjue  forward. 


opened.  In  Fig.  20  is  shown  an  excellent  form  of  forceps  for  seizing 
and  drawing  out  the  tongue  ;  one  of  these  should  be  fastened  in  a 
buttonhole  of  the  chloroformer's  coat. 

During  the  progress  of  the  narcosis  the  condition"  of  the  pulse, 
respiration,  pupils,  and  the  colour  of  the  face  must  all  be  carefully 
watched.  It  is  imj^ortant  that  the  patient's  arms  and  shoulders  should 
be  properly  placed  during  angesthetisation.  Paralysis  of  the  arm,  chiefly 
in  the  distribution  of  the  musculo-spiral,  but  also  of  the  median  and 
ulnar  nerves,  may  result  from  forcible  abduction  or  hyperextension  of 
the  arm,  which  causes  the  brachial  plexus  to  be  compressed  between 
the  clavicle  and  first  rib  or  between  the  former  and  the  transverse 
process  of  the  sixth  or  seventh  cervical  vertebra.  In  rare  cases — e,  g., 
when  the  reflexes  are  increased — these  paralyses  have  a  central  origin 
and  are  caused  by  the  chloroform.  The  prognosis  of  these  paralyses  is, 
generally  speaking,  favourable,  but  recoverv  often  I'equires  a  long 
time.  The  physician  administering  the  aufesthetic  should  have  noth- 
ing else  to  do,  and  should  let  nothing  divert  his  attention  from  his 
duties. 


§  10.]  SYMPTOMATOLOGY   OF   CHLOROFORM  ^^IRCOSIS.  27 

Decomposition  of  Chloroform  Vapour  by  tlie  Flame  of  a  Gas-light.— When 
the  vapour  of  chloroform  comes  in  contact  with  the  flame  of  a  gas-jet  there 
are  formed  tetrachloride  of  carbon,  hydrochloric-acid  gas,  and  free  chlorine 
(Bosshard),  the  latter  being  two  gases  which  according  to  Stobwasser,  when 
inhaled  by  rabbits  and  guinea-pigs,  may  cause  death  from  oedema  of  the  lungs 
and  hcemorrhages  into  the  lung  substance.  According  to  Kunkel,  the  hydro- 
chloric acid  is  the  chief  cause  of  the  discomfort  experienced  in  using  chloro- 
form by  candle  and  lamp  light.  He  found  chlorine  only  in  small  amounts, 
which  were  probably  set  free  by  the  decomposition  of  hydrochloric  acid. 

Zweifel  has  observed  bronchitis  and  pneumonia  following  the  administra- 
tion of  chloroform  by  gas-light,  on  account  of  the  decomposition  of  the  chlo- 
roform ;  and  he  himself  lost  a  patient  from  catarrhal  pneumonia.  The 
fumes  are  often  so  strong  as  to  make  everybody  in  the  operating  room  cough. 
To  overcome  this  difficulty,  Kunkel  recommends  abundant  ventilation,  or, 
if  this  is  not  possible,  as,  for  example,  during  a  laparotomy,  the  use  of  a  spray 
or  saturation  of  cloths  with  water,  milk  of  lime,  soda,  or  borax,  to  absorb  the 
hydrochloric  acid.  The  best  way  of  getting  about  the  difficulty  is  to  use 
Junker's  ap]5aratus  or  ether. 

§  10.  Symptomatology  of  Chloroform  Narcosis. — The  symptoms  of 
chloroform  narcosis  have  been  divided  into  separate  stages,  which, 
though  not  sharply  defined  from  one  another,  are  each  very  diff ei'ent. 
They  are  (1)  the  stage  of  volition,  (2)  the  stage  of  excitement,  and  (3) 
the  stage  of  tolerance.  Kappeler  speaks  of  two  stages :  one  of  con- 
sciousness, and  the  other  of  unconsciousness. 

Sometimes,  particularly  in  the  case  of  weak  and  exhausted  individ- 
uals, the  chloroform  sleep  comes  on  without  any  intermediate  stage, 
but  as  a  rule  it  is  preceded  by  a  well-marked  stage  of  excitement.  The 
patient  becomes  restless,  and  begins  to  talk,  cry  out,  shout,  sing^  laugh, 
weep,  etc.  Many  patients  fling  their  arms  and  legs  about,  try  to  get 
np,  and  act  as  though  insane.  Gradually  the  movements  of  the  arms 
and  legs  cease  ;  they  become  limp  ;  the  face,  which  has  usually  hitherto 
been  purple,  now  becomes  pale  ;  the  puj^ils  are  contracted,  and  no  longer 
react  to  light  or  mechanical  stimulation ;  the  pulse  becomes  distinctly 
slower,  the  respiration  quiet,  regular,  and  at  times  rather  shallow;  the 
patient  is  completely  insensible,  and  the  operation  can  begin. 

The  skill  of  the  chloroformer  consists  in  keeping  the  patient  in  this 
stage  of  the  narcosis  throughout  the  operation,  permitting  him  neither 
to  awake  nor  to  be  overcome  by  a  fatal  paralysis  of  respiration  or  of 
the  heart.  The  behaviour  of  the  pupils,  the  pulse,  and  the  respiration 
must  be  carefully  watched. 

When  the  ansesthesia  is  complete,  the  pupils,  which  so  long  as  con- 
sciousness was  not  entirely  lost  began  slowly  to  dilate,  now  become  con- 
tracted. By  touching  the  cornea  their  degree  of  dilatation  will  not  be 
affected,  since  the  cornea  is  without  sensation.     Sudden  dilatation  of 


28  THE   ALLKVIATIOX   OF   PAIN    DURING   OPERATIONS. 

the  pupils  (luring  the  narcosis  is  a  dangerous  symptom,  indicating  a 
threatened  fatal  cardiac  paralysis.  At  times,  in  deep  chloroform  nar- 
cosis, there  occurs  an  asymmetrical  movement  of  the  eyeballs.  In 
such  cases,  while  one  eye  may  remain  looking  steadily  forward,  the 
other  may  turn  slowly  inward,  outward,  or  upward.  In  other  cases 
both  eyes  may  turn  either  in  opposite  directions  or  varying  distances 
in  the  same  direction.  The  occurrence  of  asymmetrical  movements  of 
the  eyes  is  a  sure  indication  of  deep  narcosis ;  the  co-ordination  of  the 
ocular  movements  returns  when  the  patient  awakes. 

The  heart's  action  is  increased  at  the  beginning  of  the  chloroform 
narcosis,  and  the  pulse  becomes  more  rapid ;  but  with  the  loss  of  sensi- 
bility coincident  with  contraction  of  the  pupils  and  the  paralysis  of  the 
voluntary  muscles,  the  heart's  action  becomes  weaker  and  the  frequency 
of  the  pulse  falls  below  the  normal.  Kappeler  found  that  the  frequency 
of  the  pulse,  a  few  hours  before  narcosis,  diifered  by  from  four  to  thirty 
beats,  as  compared  with  that  dunng  the  narcosis. 

The  pulse  curves  obtained  by  the  sphygmograph  teach  that  chloro- 
form lowers  the  arterial  pressure,  and  this  is  of  great  importance  for 
the  explanation  of  the  deaths  from  chloroform.  Ether  has  the  oppo- 
site effect — it  raises  the  blood  pressure  and  the  pulse  becomes  stronger. 
Hand  in  hand  with  the  slowing  of  the  circulation  and  the  diminution 
of  the  blood  pressure  there  is  a  loss  of  body  temperature,  which,  ac- 
cording to  the  measurements  of  Kappeler,  amounts  to  between  0.2°  to 
1.1'^  C.  or  an  average  of  0.59°  C. 

The  liehaviour  of  respiration  varies  greatly  with  the  individual,  but 
both  the  frequency  and  the  depth  of  the  breathing  diminish  as  the 
administration  of  the  chloroform  is  prolonged.  Chloroform  acts  locally 
upon  the  nerves  of  the  respiratory  tract,  as  well  as  on  the  respiratory 
centre.  In  any  stage  of  chloroform  narcosis,  particularly  in  the  first, 
there  may  be  a  cessation  of  respiration,  or  its  normal  course  can  be 
seriously  interfered  with  by  the  tongue  falling  back  against  the  posterior 
wall  of  the  pharynx.  Eetching  or  vomiting  is  of  frequent  occurrence 
during  all  stages  of  chloroform  narcosis,  but  particularly  in  the  fii'st,  if 
the  patient  has  had  something  to  eat  a  short  time  previously. 

Loss  of  sensation  occui*s  first  in  the  back  and  extremities,  later  in 
the  genitalia,  then  in  the  face  and  head,  and  finally  in  the  cornea,  with 
its  abundant  nerve  supply,  and  after  the  termination  of  the  narcosis 
sensation  returns  to  these  parts  in  the  reverse  order. 

At  the  close  of  the  operation  the  patient  should  be  cai'ried  as  soon  as  pos- 
sible into  another  well-aired  and  well-warmed  room,  and  should  be  carefully 
watched  until  he  has  returned  to  complete  consciousness.  Elimination  of 
the  chloroform  takes  place  more  quickly  in  a  warm  than  in  a  cold  room. 


§11.]     ACCIDENTS  OCCUERIXG  DUEIXG  CHLOEOFORM  XAECOSIS.        29 

The  recovery  from  the  narcosis  occurs  rather  cjuicklv,  vrith  a  sud- 
den dilatation  of  the  pupils. 

Many  patients  after  awakening  act  as  though  drunk.  Women,  in  par- 
ticular, are  apt  to  be  excited,  and  weep,  or  perhaps  have  serious  fits  of  hic- 
coughing and  hysterical  crying.  Others,  particularly  children,  after  awak- 
ening fall  asleep  again,  while  still  others  cause  anxiety  by  remaining  asleep 
for  a  long  time. 

To  prevent  vomiting,  which  very  often  occurs  after  anEesthetisation, 
the  patient  should  get  very  little  to  drink.  For  the  severe  thirst  fre- 
quent rinsing  of  the  mouth  with  cold  water  is  very  serviceable.  ^^Tot 
infrequently  the  vomiting  is  severe  during  the  fii-st  twelve  to  twenty- 
four  or  even  forty-eight  hours  after  the  narcosis.  In  such  obstinate 
cases  an  ice-bag  should  be  laid  on  the  back  of  the  neck  and  over  the 
stomach,  and  strong  black  coifee,  or  iced  champagne,  or  small  pieces  of 
ice  may  be  given  at  intervals  by  mouth,  and  as  a  last  resort  a  subcuta- 
neous injection  of  morphine  may  be  administered  in  the  region  of  the 
stomach.  Xeuber  uses  a  subcutaneous  injection  of  cafEeine  two  or 
three  times  a  day  (0.03  caffeine  in  a  solution  of  1.0  caffeine  witli  12.5 
each  of  distilled  water  and  alcohol).  Too  much  water  and  ice  increase 
the  vomiting,  and  so  should  be  avoided. 

§  11.  Accidents  Occurring  during  Chloroform  Narcosis. — 1.  Yomiting. 
— Retching  or  actual  vomiting  may  occur  at  any  stage,  but  especially 
before  the  complete  loss  of  consciousness  and  toward  the  close  of  the 
narcosis.  If  the  stomach  is  full, 'vomiting  regularly  takes  place.  Oc- 
casionally death  has  been  caused  by  asphyxia,  due  to  the  inhalation  of 
stomach  contents.  During  the  act  of  vomiting  the  patient  usually  re- 
covers consciousness,  thus  causing  the  narcosis  and  the  operation  to  be 
prolonged.  When  vomiting  occurs  the  head  of  the  patient  should  be 
turned  to  one  side,  and  if  the  n.outh  is  tightly  closed  it  must  be  opened 
by  force  with  one  of  the  instruments  illustrated  on  page  2Q. 

2.  Anmyialies  of  Jiespiration.— Irregular  respiratory  movements 
are  generally— in  fact  almost  always — ^to  be  expected  during  the 
narcosis. 

In  the  beginning  of  the  latter  there  is  not  infrequently  a  cessation 
of  respiration  in  expiration,  generally  accompanied  by  a  spasmodic 
closure  of  the  glottis.  As  has  been  mentioned  on  page  28,  this  tem- 
porary apnoea  is  caused  reflexly  by  the  chloroform  vapour  coming  in 
contact  with  the  end  filaments  of  the  fifth  nerve  in  the  nasal  mucous 
m.erabrane.  But  the  danger  is  greater  if  respiration  stops  during  the 
stage  of  excitement,  giving  the  characteristic  picture  of  asphyxiation  : 
the  thorax  is  as  stiff  as  a  board,  the  jaws  are  tightly  closed,  the  tongue 
is  drawn  back  against  the  posterior  pharyngeal  wall,  pressing  down 


30  THE  ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

the  epiglottis,  and  so  closing  the  larvnx,  while  the  face  becomes  bluish 
red.  Under  these  circumstances  death  can  result ;  but  such  a  picture 
should  cause  no  alarm  in  one  who  is  experienced,  as  this  disturbance 
in  the  respiration  can  be  easily  remedied.  After  the  stage  of  excite- 
ment has  passed,  and  the  patient  is  fully  under  the  influence  of  chloro- 
form, respiration  can  be  easily  interrupted  by  the  tongue  falling  back- 
ward of  its  own  weight,  pushing  down  the  epiglottis,  and  thus  closing 
the  entrance  into  the  larynx.  The  bluish-red  colouration  of  the  face 
in  such  cases  calls  attention  to  an  interruption  in  the  respiration.  In 
other  cases  the  disturbances  of  respiration  are  caused  by  paralysis  of 
the  respiratory  centre,  due  to  the  action  of  the  chloroform  yapour. 

Liuhart  saw  a  singular  cause  for  the  asphyxia  iu  a  girl  who  had  a  very 
pointed  nose  and  extremely  thin  alaj  nasi.  The  latter  were  pressed  tightly 
against  the  septum  on  both  sides  by  atmospheric  pressure  during  inspiration 
and  thus  closed  the  anterior  nares,  and  at  the  same  time  the  mouth  could 
not  be  opened,  owing  to  trismus.  The  ala?  were  pried  apai't  with  a  penknife 
and  air  rushed  into  the  nose,  making  a  distinctly  audible  noise.  Other  sur- 
geons have  observed  the  same  phenomenon. 

3.  Disturbances  in  the  Circulation. — These  are  extremely  danger- 
ous, and  sometimes  occur  at  the  beginning  of  the  narcosis,  but  more 
frequently  after  the  administration  of  chloroform  has  been  kept  up 
some  time ;  in  other  words,  iu  the  stage  of  tolerance  or  deep  narcosis. 
Xo  matter  whether  the  respiration  is  normal  or  not,  if  the  radial  pulse 
becomes  intermittent  and  the  face  pale  there  is  need  of  the  greatest 
care  to  prevent  the  threatened  syncope  from  proving  fatal.  It  occurs 
sometimes  quite  suddenly  and  without  warning,  and  the  impending 
danger  is  not  foretold  by  irregularity  of  the  pulse.  In  a  case  of  chloro- 
form syncope  the  face  turns  very  suddenly  waxy  white  and  corpselike, 
the  cornea  becomes  dull,  the  pupils  are  clilated  to  their  fullest  extent 
and  do  not  react,  the  radial  pulse  can  not  be  felt,  the  heart  sounds  are 
very  faint  or  inaudible,  blood  ceases  to  flow  from  the  divided  arteries, 
or  the  blood  that  does  flow  out  is  in  the  form  of  a  few  dark  drops,  the 
muscles  become  flabby,  and  respiration  ceases.  This  is  the  picture  of 
cardiac  paralysis.  Energetic  measures  must  be  adopted  at  once,  other- 
wise the  patient  is  lost  (see  §  13). 

§  12.  The  Occurrence  and  Causes  of  Death  from  Chloroform. — The 
number  of  published  deaths  due  to  chloroform  does  not,  of  course, 
give  any  idea  of  their  frequency.  The  fatal  cases  are  much  too  often 
kept  quiet. 

Legal  Responsibility  of  the  Physician  in  Cases  of  Death  during  Nar- 
cosis.— Borntrager,  E.  Hankel,  and  Dumont  have  made  noteworthy 
contributions  to  the  subject  of  the  legal  responsibility  of  the  physician 


§  12.]    OCCURRENCE  AND  CAUSES  OF  DEATH  FROM  CHLOROFORM.     31 

in  the  administration  of  chloroform  and  other  anaesthetics  ;  and  Dumont 
maintains  that  the  physician  is  answerable  for  a  death  when  he  admin- 
isters ether  to  a  patient  with  pnlmonarj  disease,  and  chloroform  to  one 
with  a  cardiac  lesion.  I  should  not  consider  this  assertion  of  much 
legal  value,  as  a  correct  decision  can  only  be  reached  after  considera- 
tion of  each  case  by  itself. 

Death  from  chloroform  occurs  in  most  cases  suddenly  during  the 
administration  of  the  same.  Sometimes,  however,  it  does  not  take 
place  until  one  or  more  days  afterwards,  in  spite  of  the  fact  that  the 
patient  has  come  out  of  its  influence.  This  is  likely  to  be  the  case 
when  the  narcosis  has  been  prolonged,  or  has  been  repeated  a  number 
of  times  at  short  intervals.  These  cases  are  characterised  by  frequent 
and  severe  vomiting,  high  pulse  rate,  psychical  disturbances,  and  symp- 
toms of  collapse,  during  which  death  takes  place  more  or  less  suddenly. 

Statistics  of  Death  from  Chloroform.— The  statistics  showing  the  fre- 
quency of  death  from  chloroform  vary  very  widely.  Rendle  (Loudon)  esti- 
mates the  mortality  of  chloroform  anaesthesia  at  Ito  2,666,  and  Zachrisson  at 
1  to  3,045.  Richards  found  the  ratio  for  eight  Enghsli  hospitals  from  1848 
to  1864  to  be  1  to  17,000,  and  from  1865  to  1869  1  to  1.250.  There  is  a  very 
noticeable  difference  in  the  statistics  of  the  various  hospitals. 

In  one  hospital  a  long  interval  of  time  will  pass  with  a  great  number  of 
cases  of  chloroform  narcosis  without  a  single  death,  while  in  another,  in  the 
same  time  and  with  the  same  number  of  cases,  there  are  several  accidents. 
This  variation  in  the  proportion  of  chloroform  deaths  in  this  or  that  hos- 
pital can  be  partly  explained  by  the  greater  or  less  skill  of  the  one  intrusted 
with  the  administi'ation  of  the  drug. 

Rendle  estimates  the  number  of  peo^jle  chloroformed  yearly,  in  the 
twenty  hospitals  in  London,  at  8,000,  with  about  three  deaths,  or  1  in  2.666. 

Billroth  had  his  first  fatal  case  after  giving  chloroform  12.500  times. 
Nussbaum  gave  it  15.000  times  without  a  death. 

The  mortality  statistics  of  the  Deutsche  Gesellschaft  fiir  Chirurgie  showed 
in  1897  a  total  of  327.593  narcoses  and  134  deaths — i.  e.,  a  ratio  of  1  to  2.444. 
The  mortality  of  the  different  anaesthetics  used  was  as  follows  :  Chloroform, 
1  death  in  2,039 ;  ether,  1  in  5.090  fpneumonia  resulted  frequently — in  1895, 
out  of  30  cases  of  pneumonia  15  died)  ;  Billroth  s  chloroform-ether-alcohol 
mixture  (see  page  46),  1  in  3,870 ;  bromethyl,  1  in  5,228 :  ether  and  chloro- 
form, 1  in  7,594  ;  pental.  1  in  213.  This  anaesthetic  is  not  found  in  the  reports 
of  the  later  years.     It  has  probably  been  given  up  entirely. 

The  mortality  from  chloroform  as  well  as  from  ether  is  higher  than 
reported,  as  so  many  fatal  cases  are  kept  quiet.  Though  there  are  great  dif- 
ferences in  the  statistical  reports  regarding  the  mortality  of  chloroform,  one 
fact  is  certain — viz.,  that  chloroform  anaesthesia  is  not  without  danger,  and 
hence  should  be  employed  only  when  absolutely  necessary.  When  possible, 
local  anai.sthesia.  which  is  practically  without  danger,  should  be  substi- 
tuted. According  to  the  above  statistics,  the  combined  anaesthesia,  with 
chloroform  and  ether,  is  the  least  dangerous. 


32  THE   ALLEVlATIOy  OF  PAIX  PURIXG  OPERATIONS. 

To  get  a  bener  knowledge  of  me  causes  of  death  from  cidorofomi.  Kap- 
peler  collected  the  recwds  of  one  hundred  and  one  cases,  seventy-eight  of 
which  wav  men  and  twenty-two  wMnen ;  in  one  case  the  se:s  was  not  men- 
tioned. Of  these  one  hundred  and  one,  forty-three  died  before  the  full  effect 
of  the  chlMtrf <wni  wAs  obtained,  fwty-seven  in  deep  narcosis,  and  in  eleven 
the  particular  stage  of  the  nareo^  is  not  mentioned.  The  amount  of  chloro- 
ionn  i^ed  is  known  in  f fflrty-sLs  cases,  and  it  was.  as  a  general  thing,  small, 
av^aging  11.1  grammes,  ti^  smalls  amount  being  twenty  drops,  and  the 
most  thirtv  to  asly  grammes  Veiy  diverse  methods  of  administering  the 
chloMrfonn  were  used,  such  as  sgnnkling  it  on  simple  pieces  of  cloth,  cotton, 
or  the  x^ular  a^aratns  of  S^xoner.  Esmarch.  and  otheis.  As  to  the  age  of 
ibe  patients  who  wae  op»ated  upon  for  difB^«nt  diseases,  two  died  under 
five  vears  <rf  age  twelve  between  the  ages  of  five  and  fifteen,  nineteen  be- 
tween sixteen  and  thirty,  twenty-one  between  thirty-one  and  forty-five, 
twenty-five  between  ftHty-six  and  sixty.  Of  those  over  sixty  years  of  age 
<me  died.    In  twenty-one  c^£S  the  age  is  not  given. 

OasEes  of  Bea&  firm  GUflnrfacn. — ^The  causes  of  death  frota  chloroform 
are  verv  varied,  and  frequently  the  ehhxofonn  is  not  to  blame  at  alL  K  a 
patient  ch<fes  fipcMn  aspirating  vcHnitus  into  the  trachea  and  bronchi,  or 
frcmi  getting  a  s^  of  false  te^th  into  his  larynx  during  the  chloroform  narco- 
ss,  this  9«t  of  death  is  plainly  not  due  to  the  chltMof  orm.  A  certain  num- 
b^  of  bidden  deadis  take  place  even  b^ore  the  administration  of  the  chloro- 
fonn  has  been  b^nn.  Desault,  for  instance;  was  about  to  perform  a  lithot- 
<Mny.  and.  to  d^non^trate  to  the  ^ledatois  his  line  of  incision,  drew  his 
finga^nail  over  the  patient's  perin£enm.  whereupon  the  latter  suddenly 
iitl»ed  a  loud  cry  and  died  instantly.  Cazenave  was  grang  to  perform  an 
ampnlatitm.  but  the  patient  was  in  such  a  state  of  nervous  depression  that  he 
did  not  veotnre  to  give  him  chl(Kt>f (Km,  and  only  pr^iended  to  do  so  by 
holding  a  cloth,  with  nothing  (Hi  it.  over  his  face.  Suddenly  his  respiration 
stored,  his  heart  ceased  to  beat,  and  the  patient  was  dead.  The  first  patient 
to  wIhsdo.  ^nipson  attempted  to  administier  chl(»t>fcHnn  died  under  similar 
eireumstances.  The  attendant  who  was  to  Ixing  the  chlorof (M'm  into  the 
(^srating  room  stumbled,  fell,  and  Intike  the  bolUle  containing  the  drug. 
and  ^lled  all  tiie  chhxofnm  (mi  tiie  Soor.  The  operation,  which  was  for 
honia  «1iemiot(Mny).  had  to  be  performed  without  chlcrofonn.  and  at  the 
fiist  inc^(Hi  tiirongfa  the  din  the  patient  died.  It  is  diffi(nilt  to  give  a  satis- 
faetory  exp]anati(Hi  for  titese  sudden  dpathsL  They  are  probably  the  result 
of  a  syncope  due  to  ibe  intraise  novons  excitement.  Sudden  deaths  during 
the  administration  of  ciHardfana  also  oecvr  in  young  individuals  from 
twelve  to  thiri^  years  of  age  witii  a  lymphatic  and  chlorotic  (xmstitution 
(hyperpla^  of  the  thymic  enlargt^nent  of  the  spleen  and  lymph  glands, 
^tie. — ^atus  fhymicusX  FurthermcHe.  in  eases  which  must  be  operated  upon 
after  having  Ic^t  a  great  deal  of  blood,  if  death  occurs  from  cardiac  paralysis 
dnxing  the  administration  of  the  chloroform,  it  is  not  to  be  put  down  to  the 
satae^Oadtie.  ^We  mnst  s^arate  all  these  cases  of  death  octnnnng  during  the 
nareoas  &om  the  c:^ses  of  deatii  really  caused  by  cblcrofoan.  In  the  latter. 
death  is  eanaed  prineipally  by  paralysis  of  the  heart  (syncope)  or  paralysis 
of  res^ration  CasphyxiaK  In  cases  of  death  from  syncope,  the  hearts 
action  ceases  bef (Mie  or  almost  at  tiie  same  time  that  respiration  does :  but 


§  12.]  OCCUBBENCE  AST)   CAUSES  OF  DEATH  FBOM  CHLOBOFOBIL  33 

Ib  cases  of  death  from  asphyxia  the  p^piraticHi  ceas^  firsts  and  the  heart's 
action  afterwards.  In  anr  case,  whether  the  result  of  syncope  or  a^hjida, 
death,  can  occur  before  or  dxaing  the  time  that  the  faQ  eCTect  of  chlosofann 
is  obtained,  and  therefore  at  the  beginnings  or  at  any  period  of  the  nareo^ 
proper. 

Of  the  twenty-three  cases  of  death  from  syncope  which  Kappeler  col- 
lected, fourteen  patients  weie  completelT  and  nine  partially  chlotofomied. 
Death  from  asphyxia  occurred  ten  times  daring  complete  and  sevai  tim^ 
daring'  partial  narcosis.  If  death  occurs  in  the  first  part  of  tme  narco^s, 
and  therefore  before  the  full  effect  of  chlcHtxfcHin  has  been  obtained,  the 
cessation  of  respiration,  or  the  cessation  of  the  heart's  action^  is  in  all  ^ob- 
ability  dependent  upon  the  trigeminus-Tagus  reflex,  as  mentioned  on  page 
20.  Death  from,  asphysia  in  the  stage  of  incomplete  narco^  may  also  be 
caused  by  spasmodic  retraction  of  the  tongue  over  the  entrance  of  the  larynx, 
or  by  spasm  of  the  abdomioal  muscles  or  of  the  diaphragm.  Death  from 
chloroform  in  the  stage  of  deep  narcosis  is  caused  by  the  direct  paraly^s  of 
the  circulatory  and  respiratory  centres  in  the  medulla  oblongata ;  but  d^tfa 
from  asphyxia  during  this  same  stage  can  also  occur  if  the  tongue  falls  back 
ever  the  entrance  into  the  larynx. 

When  death  occurs  with  the  patient  fully  und^  the  influence  of  ehloso- 
f  orm.  it  is  usually  the  result  of  heart  failura  The  blood  pressure  falk  becaiKe 
the  heart  action  weakens,  but  not  from  paralysis  of  the  Tasomotor  eaitre. 
The  latter  seems  to  withstand  the  paralysing  action  of  chlonrffxm  betl^ 
than  the  nervous  mechanism  of  the  heart  particularly  if  it  obtain  suffieieiit: 
oxygenated  blood.  The  same  seems  to  be  true  of  the  re^iratosy  centre,  and 
the  peripheral  nerves  in  the  lungs  ^pnenmogastric).  If,  howeri^,  the  blood, 
in  consequence  of  impaired  breathing,  is  overloaded  with  carbonic  acid,  fatal 
paralysis  of  the  vaso-motor  and  respiratory  centres  can  move  easily  occur 
(Evans).  The  theory  advanced  by  Bobin  and  Chapoaan  that  chlorafonn 
kills  by  extracting  oxygen  from  the  blood,  cw  preventing  its  bein^  taken  up 
by  the  blood,  is.  according  to  T\noll's  experiments,  no  Icsiger  tenable.  A 
fatal  outcome  is  favotired  by  an  impure  preparatioai,  by  the  irae  oi  too 
concentrated  a  mixture  of  air  and  chlorofmn,  by  individual  peculiarities  of 
the  patient  and  by  lack  of  skill  on  the  part  of  the  ansestibetist.  cocsistizig 
particularly  in  failure  to  vratch  the  pulse  and  respiration. 

How  far  impure  chlorofarm  is  respon^ble  few  death  in  th^  or  :   -t 

is  difficult  to  say.    Dangerous  methyl  annpounds  (see  page  19)       -  r 

feared. 

It  has  been  proved  by  numerous  e^perimente  13iat  it  is  psir;:i^u^^ii^y 
dangerous  to  inhale  chlorofcHin  vapour  in  too  ctHicentrated  a  faim,  and 
Snow.  Sanson,  and  the  English  committee  which  investigated  the  cases  oi 
death  from  chloroform  published  an  urgent  wuming:  <hi  this  point.  Lalle- 
mand,  Perkin.  and  Dnroy  showed  that  mamTnals  will  quickly  die  if  they 
are  made  to  breathe  a  mixture  consisting'  of  S  parts  of  ehl<Haf<Hm  to  100  <rf 
air.  while  they  can  safely  breathe  a  four-per-cent.  mixture.  Aeeoardrng  to 
Snow.  5  parts  of  chloroform  to  95  par^  of  air  can  be  safely  inhaled,  but 
mammals  will  die  if  the  mixtore  fe  made  eight  or  ten  per  cent,  by  volume. 
According  to  the  English  Chl<»ofc»rm  Committee,  the  drug;  should  only  be 
inhaled  in  the  strength  of  three  and  a  half  to  four  and  a  half  pear  csit., 
4 


31  THE   ALLEVIATION   OF   PAIN  DURING   OPERATIONS. 

aud  never  in  the  form  of  concentrated  vapour,  the  latter  being  the  chief 
cause  of  the  sudden  reflex  stoppage  of  respiration  and  slowing  of  the  heart 
from  stimulation  of  the  filaments  of  the  trigeminal  nerve  in  the  nose  and 

throat. 

Bert  came  to  the  same  conclusions  in  his  experiments  on  dogs.  Accord- 
ing to  him  there  are  two  limits  for  the  action  of  chloroform,  one  for  anaes- 
thesia (10  parts  of  chloroform  to  100  of  air),  and  one  for  immediate  death 
(20  to  100).  Tlie  best  plan  is  to  use  a  strong  dose  of  chloroform  to  produce 
immediate  anaesthesia,  and  then  to  continue  the  anicsthesia  with  weak  mix- 
tures of  air  and  chloroform.  Generally  speaking,  the  proper  mixture  is  S 
grammes  of  chloroform  to  100  litres  of  air.  The  experiments  conducted  by 
Bert  show  that  we  use  our  anaesthetics  in  much  too  large  amounts,  aud  in 
too  great  concentration. 

The  Influence  of  Pathological  Conditions  upon  Death  from  Chloroform.— 
What  pathological  conditions  favour  the  occurrence  of  death  from  chloro- 
form, and  what  does  the  post-mortem  examination  teach  on  this  subject  ? 
In  the  first  place  it  should  be  emphasised  that  many  individuals  without 
demonstrable  pathological  lesions  are  markedly  susceptible  to  the  injurious 
effects  of  chloroform.  Young  scrofulous  and  anaemic  persons  under  thirty 
years  of  age,  with  hypertrophy  of  the  thymus  and  the  thyroid  gland  (status 
thymicus,  Paltauf)  belong  to  this  class. 

In  general  there  may  be  mentioned,  as  dangerous  complications  of  chlo- 
roform narcosis,  fatty  degeneration  of  the  muscles  of  the  heart,  valvular 
lesions,  atheromatous  degeneration  of  the  walls  of  the  vessels,  particularly 
of  the  coronary  arteries,  anaemia,  chiefly  as  a  result  of  excessive  loss  of  blood, 
chronic  pulmonary  disease,  such  as  emphysema,  diseases  of  the  kidney  (mor- 
bus Brightii),  and  chronic  alcoholism.  In  all  such  cases  the  narcosis  must- 
be  conducted  with  the  greatest  caution.  Fatty  degeneration  of  the  muscles 
of  the  heart  is  particularly  dangerous.  Sanson  found  fatty  heart  in  eighteen 
out  of  fifty-six  cases  of  death  from  chloroform,  and  Kappeler's  statistics  show 
it  sixteen  times  in  sixty  cases. 

Nothnagel,  Ungar,  Strassman,  and  Ostertag  have  shown  that  dogs  kept 
for  hours,  during  several  days  in  succession,  under  the  influence  of  chloro- 
form, die  from  extensive  fatty  degeneration,  the  autopsy  showing  fatty 
deo"eneration  of  the  heart,  liver,  kidneys,  voluntary  muscles,  stomach,  and 
mucous  membranes.  Drunkards,  as  a  general  thing,  bear  the  narcosis  badly, 
and  it  is  characteristic  for  them  to  show  marked  disturbances  of  the  nervous 
and  muscular  systems,  with  threatened  cessation  of  respiration,  and  with 
great  tendency  to  collapse.  Diabetics  are  also  not  good  subjects  for  chloro- 
form or  ether.  They  die  not  infrequently  tw^o  or  three  days  afterwards  in 
coma.  According  to  Becker,  the  acetonuria  (a  sign  of  increased  amount  of 
albumen)  which  is  present  plays  an  important  part  in  the  fatal  outcome  of 
this  diabetic  coma  following  anaesthesia.  The  severer  forms  of  acute  or 
chronic  anaemia  increase  the  chances  of  death  from  syncope,  and  it  is  well 
known  that  the  activity  of  the  central  nervous  system  depends  upon  the 
amount  of  blood  circulating  through  it,  and  the  proportion  of  oxygen  which 
it  contains.  If  two  animals  of  the  same  size  are  taken,  and  the  same  amount 
of  chloroform  is  given  to  each,  and  venesection  is  performed  upon  one,  the 
latter  wdll  die  before  the  other. 


§  12.]    OCCURRENCE  AND  CAUSES  OF  DEATH  FROM  CHLOROFORM.     35 

Chloroform  Poisoning. — Acute  chloroform  poisoning-,  which  results  from 
drinking  large  amounts  of  chloroform,  has  been  observed,  particularly  in 
small  children,  but  the  children  generally  recover  with  proper  treatment — 
artificial  i^espiration,  washing  out  the  stomach,  etc. 

The  Results  of  Autopsy  in  Cases  of  Death  from  Chloroform.— The  au- 
topsy in  cases  of  death  from  chloroform  generally  reveals  little  that  is  char- 
acteristic, and  often  gives  no  satisfactory  explanation  of  the  cause  of  death. 
Not  infrequently,  however,  the  above-mentioned  changes  in  the  viscera  are 
present,  and  after  protracted  anaesthesia,  as  well  as  in  the  cases  that  die  from 
collapse  three  or  four  days  later,  thei^e  are  found  fatty  degeneration  of  the 
heart,  blood-vessels,  liver,  kidneys,  and  striated  muscles.  According  to 
Luther,  these  degenerative  changes  in  the  cells  of  the  various  organs  are 
conditioned  upon  a  lecithin  degeneration  of  the  cell  protoplasm.  He  explains 
the  fatal  effect  of  the  chloroform  from  this  degeneration,  and  from  the  pres- 
ence of  the  alkaloid  cholin,  which  is  derived  from  the  lecithin.  The  blood  is 
ordinarily  uncoagulated  and  dark  coloured,  but  microscopic  or  chemical 
examination  of  it  has  hitherto  given  no  satisfactory  explanation  for  death. 
It  is  worth  noting,  however,  that,  as  a  result  of  the  disturbance  of  respiration, 
the  blood  is  overloaded  with  carbonic  acid.  An  observation  made  by  Reck- 
linghausen is  interesting  in  this  connection.  In  three  cases  he  found  bubbles 
of  gas  in  the  great  venous  trunks  and  in  the  heart,  and  in  each  instance  death 
occurred  very  quickly  after  taking  a  very  small  amount  of  pure  chloi'oform, 
the  pulse  stopping  suddenly,  while  shallow  bi'eathing  continued  for  a  short 
time  afterwards.  It  could  not  be  determined  what  the  bubbles  of  gas  were, 
and  Sonnenberg  was  unable  to  elucidate  this  point  by  experiments  upon 
animals.  The  experiments  only  showed  that  nitrogen  under  certain  cir- 
cumstances is  set  free  within  the  blood-vessels.  Before  the  above  obsei'va- 
tion  was  made,  Langenbeck  and  Pirogoff  had  also  noticed  considerable 
amounts  of  gas  in  the  large  venous  trunks  and  in  the  right  ventricle  of  the 
heart  in  cases  of  death  from  chloroform.  Kappeler's  more  recent  researches 
have  shown  that  this  evolution  of  gas  is  not  peculiar  to  the  death  from 
chloroform,  but  is  due  to  post-mortem  changes.  If  the  gas  is  set  free  to  any 
extent  during  life,  or  if  its  presence  was  caused  by  venesection,  death  is  pro- 
duced by  mechanical  interference  with  the  heart's  action,  as  happened,  for 
example,  in  Pirogoff's  case.  Mention  should  be  made  of  the  fact  that  Wino- 
gradow  found  granular  degeneration  of  the  ganglia  of  the  heart  and  of  the 
nerve  cells  of  the  brain  and  the  spinal  cord  in  both  men  and  animals  after 
death  from  chloroform. 

Narcosis  with  a  Mixture  of  Chloroform  and  Oxygen.— J.  Neudorfer  tries 
to  explain  the  common  accidents  and  fatal  results  from  chloroform  narcosis 
in  the  following  way  :  The  affinity  of  haemoglobin  for  oxygen  is  not  constant, 
and  varies  with  the  condition  of  health,  being  now  less,  now  greater,  accord- 
ing to  the  general  vitality  of  the  individual :  and  so,  according  to  Neudorfer, 
when  this  affinity  is  weak  the  haemoglobin's  power  of  absorbing  oxygen  is 
more  influenced  not  only  by  the  oxides  of  carbon  and  nitrogen,  but  also  by 
other  gases  and  vapours,  by  temperature,  and  by  atmospheric  pressure,  than 
when  the  affinity  is  stronger.  In  case  of  a  weak  affinity  it  is  possible  that 
the  hemoglobin  may  take  up  little  or  no  oxygen,  and  that  hence  the  chloro- 
form may  exercise  its  poisonous  action.     Neudorfer  recommends  a  three-  to 


36 


THE  ALLEVIATION   OF  PAIN   DURING   OPERATIONS. 


ten-per-ceut.  mixture  of  chloroform  and  oxygen  as  the  least  dangerous  way 
of  admiuisteriug  the  drug. 

§  13.  Treatment  of  Common  Accidents  Occurring  during  Chloroform 
Narcosis. — Tlie  common  accidents  that  may  occur  during  chloroform 
auiesthesia  are :  (1)  Vomiting ;  (2)  disturbances  of  the  respiration  and 
heart's  action.  In  every  case  the  chloroform  should  be  stopped  at 
once.  If  the  patient  vomits,  his  head  should  be  turned  to  one  side, 
the  mouth  is  quickly  opened  by  means  of  one  of  the  gags  shown  in 
Fios.  24  and  25,  and  the  vomited  material  is  removed  by  wiping  out 
the  mouth.  The  chief  anxiety  consists  in  overcoming  the  impedi- 
ments to  respiration,  and  restoring  the  heart's  action. 

Overcoming  Mechanical  Interference  with  Respiration. — The  impedi- 
ment to  respiration  may,  in  the  first  place,  be  caused  by  the  occlusion 
of  the  opening  into  the  larynx  by  the  tongue.  In  order  to  free  the 
air-passage  in  such  a  case  we  have  three  means  :  (1)  Push  forward  and 

raise  the  lower  jaw ;  (2)  draw  out 
the  tongue ;  (3)  elevate  the  thorax 
and  let  the  head  and  neck  fall  back 
(Howard). 

To  draw  forwai-d  and  lift  up  the 
lower  jaw,  seize  the  latter  l)ehind 
the  angle  and  push  it  forward  and 
upwards  (Fig.  27).  By  this  proced- 
ure the  tongue  and  hyoid  bone  are 
drawn  forward,  rendering  the  hyo- 
epiglottic  ligament  tense,  and  this 
immediately  lifts  the  epiglottis  and  opens  the  entrance  to  the  larynx. 
The  tongue  forceps  illustrated  in  Fig.  26  is  another  means  of  effecting 
the  same  result ;  or  a  loop  of  thread  may  be  similarly  used,  or  a  pointed 
hook  may  be  passed  behind  the  middle  of  the  body  of  the  hyoid  bone 
to  draw  it  forward  (Braune).  Another  good  plan  is  to  pass  the  fore- 
finger down  to  the  epiglottis,  and  by  raising  it  open  the  larynx. 

By  Howard's  plan  of  extending  the  head  and  neck  backwards,  the 
point  of  support  of  the  tongue,  which  had  fallen  back  when  the  patient 
was  in  the  horizontal  position,  is  changed  from  the  posterior  w^all  of 
the  pharynx  to  the  hard  palate  or  the  boundary  between  the  hard  and 
soft  palates,  thus  making  free  for  the  stream  of  air  the  space  between 
the  root  of  the  tongue  and  the  posterior  pharyngeal  wall 

Artificial  Respiration 
the  interrupted  breathing,  artificial  respiration  must  be  begun  imme- 
diately. It  is  absolutely  essential  in  performing  artificial  respiration 
that  the  air  really  obtains  a  free  entrance  to  the  lungs.     Hence  the 


Fig.  27. — The  manner  of  pushing  forward  the 
lower  jaw  for  threatened  asphyxia. 


If  these  measures  are  not  enough  to  restore 


13.]  TREATMENT  OF  ACCIDENTS  DURING  CHLOROFORM  NARCOSIS.    37 


Fig.  28. — Artificial  respiration. 


tongue  should  be  drawn  well  out  of  the  mouth  ;  fluids  or  foreign  bodies 
should  be  removed  by  lowering  the  head,  or  by  placing  the  patient  on 
his  abdomen,  supporting  the 
epigastrium  and  forcibly  com- 
pressing the  latter,  or  finally 
by  aspiration  with  a  rubber 
catheter.  Tracheotomy  may 
be  necessary.  Every  second 
increases  the  danger  of  the 
threatened  death,  particularly 
if  the  pulse  is  irregular  and  if 
the  face  becomes  deadly  pale 

or  bluish.  Artificial  respiration  is  performed  with  the  patient  in  the 
position  indicated  in  Fig.  28.  The  operator  grasps  the  lower  portion 
of  the  thorax  and  makes  vigorous  rhythmical  expiratory  movements 

by  pressing  together  the 
lower  lateral  portions  of  the 
thorax.  At  the  same  time 
the  lower  jaw  is  elevated 
and  the  tongue  drawn  for- 
ward. Laborde  recommends 
rhythmical  traction  on  the 
tongue  by  grasping  its  pos- 
terior portion  (fifteen  to 
twenty  times  a  minute). 
This  is  supposed  to  stimu- 
late the  respiratory  centre 
indirectly  through  the  laryn- 
geal nerve. 

Silvester's  method  for 
performing  artificial  respi- 
ration is  better  (Figs.  29,  30)- 
The  patient  is  placed  as 
quickly  as  possible  in  the 
horizontal  position,  or  with 
the  head  directed  down- 
wards ;  the  operator  stands 
behind  the  patient,  and, 
grasping  the  arms,  flexed  at 
the  elbow,  presses  them  lat- 
FiG.  30.  erally  against  the  chest  and 

Figs.  29  and  30.— Artificial  respiration  (Silvester).         then    drawS   the    armS   back- 


FiG.  29. 


38  TBE  ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

wards  till  they  are  stretched  out  horizontally  above  the  head.  In  this 
procedure  the  ribs  are  raised  by  the  traction  of  the  pectoral  muscles. 

Schiiller  has  recommended  grasping  the  arch  of  the  ribs  on  both 
sides,  and,  after  vigorously  raising  them,  pressing  them  do^vn  against 
the  thoracic  cavity.  The  experiments  and  manometric  measurements 
made  by  Djelitzin  show  that  the  Silvester  and  Schiiller  methods  of 
producing  artiticial  respiration  are  the  Ijest.  Artiiicial  respiration 
should  be  combined  with  vigorous  blows  over  the  region  of  the  heart, 
which  stimulate  its  action.  Kraske  has  shown  that,  even  after  the 
heart  has  stopped  beating,  a  kind  of  circulation  can  be  kept  up  for  a 
certain  length  of  time  by  artificial  respiration  and  by  compression  of 
the  heart  while  the  head  is  kept  lowered.  The  deep  inspiratoi-y  move- 
ments aspirate  the  venous  blood  into  the  right  auricle. 

Electrical  stimulation  of  the  phrenic  nerves  is  another  method  of 
resuscitation  (Duchenne).  The  electrodes  of  an  induction  apparatus 
are  moistened  and  placed  on  either  side  of  the  neck,  at  the  outer  border 
of  the  stemomastoid  muscle,  which  is  pressed  somewhat  towards  the 
median  line,  and  near  the  lower  end  of"  the  scalenus  anticus.  This 
stimulates  not  only  the  phrenic  nerves,  with  the  muscle  they  supply  (the 
diaphragm),  but  also  other  nerves  and  muscles  of  inspiration  (scalenus 
anticus,  stemomastoid,  pectorales,  serrati,  etc.).  The  stimulation  should 
be  interrupted  about  every  two  seconds,  and  expiration  should  be  aided 
by  compressing  the  thoracic  and  upper  abdominal  walls. 

The  insufflation  of  air  by  means  of  a  catheter  introduced  into  the 
larynx  is  not  to  be  recommended.  It  may  be  necessary  to  perform  a 
raj)id  tracheotomy  and  then  do  artificial  respiration  or  insufilate  air. 

In  desperate  cases  artificial  respiration  should  l)e  kept  up  from 
half  an  hour  to  an  hour,  or  even  longer.  Life  has  been  known  to  be 
restored  after  working  twenty  minutes,  even  when  any  measure 
seemed  at  first  hopeless.  There  are  successful  cases  on  record  in 
which  artificial  respiration  was  performed  for  three  to  four  hours  on 
people  who  were  apparently  drowned.  Artificial  respiration  is  also 
the  best  and  surest  way  of  restoring  the  action  of  a  heart  which  is 
failing  or  has  become  imperceptible.  The  direct  mechanical  effect  of 
compression  and  movement  of  the  thoracic  organs  seems  to  have  a 
stimulating  power  over  the  heart's  action.  The  inversion  or  lowering 
of  the  head,  accompanied  by  artificial  respiration  (Kelaton,  Tiichard- 
son,  and  others),  appeai-s  to  be  particularly  advantageous  in  cases  of 
syncope  from  chloroform. 

Electro-puncture  of  the  Heart.— It  has  been  recommended  to  stimulate 
the  heart  by  introducing-  into  its  substance  a  needle  charofed  with  an  electric 
current  (acupuncture  or  electro-puncture) ;  but  this  need  only  be  mentioned 


§  14]  ETHER  NARCOSIS.  39 

to  be  condemned  as  too  dangerous.  Sigmund  Mayer  has  shown  that  this 
direct  electrical  stimulation  of  the  heart  by  an  interrupted  or  constant  cur- 
j'ent  acts  as  a  heart  poison.  Watson  experimented  on  animals,  and  found 
the  heart  could  be  punctured  without  danger,  but  if  the  vena  cava  was  en- 
tered it  was  followed  by  a  profuse  hgemorrhage  into  the  thoracic  cavity.  The 
j-ight  ventricle  was  entered  thirty-eight  times,  the  left  six  times ;  the  right 
-auricle  was  entered  six  times,  the  vena  cava  superior  three  times,  the  vena 
cava  inferior  twice,  and  the  apex  twice. 

Of  the  other  means  which  are  recommended  as  restoratives  to  be  used  in 
addition  to  artificial  respiration,  if  the  breathing  or  heart  action  stop,  I  shall 
mention  the  following :  Sprinkling  the  face  with  cold  water ;  slapping  the 
cheeks,  forehead,  or  breast  with  the  hand  or  with  a  wet  towel ;  methodical 
rubbing  of  the  extremities  so  as  to  assist  the  peripheral  circulation  and  stimu- 
late the  cutaneous  nerves  ;  autotransfusion  (see  page  57)  ;  and  the  subcuta- 
neous injection  of  a  sodium  chloride  solution.  W.  Koch  recommends  plac- 
ing the  uncovered  pole  of  the  induction  apparatus,  or  the  copper  wire  itself, 
-deep  in  the  nasal  cavity,  and  permitting  a  strong  current  to  act  directly  on 
the  nasal  mucous  membrane  for  ten  to  twenty  seconds.  After  a  single  or 
repeated  stimulation  there  usually  occurs  a  deep  inspiration  or  expiration, 
and  breathing  proceeds  without  assistance. 

Should  the  respiration  begin  again,  and  the  pulse  become  regular, 
suitable  stimulants  should  be  administered — olfactory  stimulants,  stimu- 
lating enemas  of  vinegar,  wine  mixed  with  water,  or  wine  alone,  sub- 
cutaneous injections  of  camphor  or  ether,  etc. 

As  a  prophylactic  measure,  particularly  in  the  case  of  very  weak, 
frightened,  or  e.xcited  individuals,  it  is  wise  to  administer  some  alco- 
iolic  stimulant  before  the  operation,  such  as  Bordeaux  or  Marsala  wine, 
and  cognac  to  individuals  accustomed  to  the  use  of  alcohol. 

The  other  Compounds  of  Methyl.— The  other  compounds  of  methyl- 
methyl  ether,  methylene  bichloride,  methylene  ether,  and  methylal— are  now 
hut  little  used  in  surgery  as  anassthetics.  Methylene  bichloride  alone  has 
found  some  warm  adherents  in  Spencer  Wells,  Marshall,  Gaingee,  and  other 
English  surgeons.  The  drug  possesses  no  real  advantage  over  chloroform, 
and  only  seems  to  be  less  liable  to  cause  vomiting.  Its  disadvantages  are  its 
inflammability  and  expensiveness.  Furthermore,  its  use  is  not  free  from 
danger— in  fact,  it  is  probably  more  dangerous  than  chloroform.  Kappeler 
mentions  nine  fatal  cases.  Methylene  bichloride  is  best  administered  by 
Junker's  apparatus,  which  is  illustrated  on  page  25. 

§  14.  Ether  Narcosis.— Ether  is  another  much-used  ansesthetic 
which  is  coming  to  be  employed  more  and  more  in  the  place  of  chlo- 
roform or  its  compounds.  In  America,  ether  narcosis  is  used  almost 
exclusively,  and  in  England,  France,  Switzerland,  and  even  Germany, 
this  drug  is  coming  into  constantly  growing  favour.  I  am  very  much 
pleased  with  ether  as  an  anaesthetic,  having  used  it  in  about  three  thou- 
sand cases  without  any  serious  after  effects. 


40  THE   ALLEVIATION   OF   PAIX   DURING   OPERATIONS. 

Ethei- — sulphuric  etlier.  naphtha,  etliylether.  C4H10O— is  a  colourless, 
easily  diffusible  liquid  possessing  a  pleasant  odour  and  burning  taste.  Ether 
is  very  volatile  and  inflammable,  and  boils  at  a  temperature  of  38°  C.  Its 
specific  gravitA-  at  15°  C.  is  0.720.  Ether  that  is  to  be  u.sed  for  anaesthesia 
must  be  pi'otected  from  light  and  air.  and  the  bottles  containing  it  should  be 
kept  filled.  Its  purity  can  be  tested  in  the  following  way :  Twenty  cubic 
centimetres  are  allowed  to  evaporate  in  a  shallow  glass.  The  moist  scum 
left  behind  must  be  odorless,  and  should  turn  blue  litmus  paper  neither  red 
nor  white.  If  a  few  drops  of  a  ten-per-cent.  solution  of  feri'osulphate  are 
covered  with  ether  in  a  watch  glass,  and  a  few  drops  of  caustic  soda  are 
added,  the  fluid  should  not  turn  brown  inside  of  a  minute. 

The  physiological  action  of  ether  is  essentially  the  same  as  that  of  chlo- 
roform, except  that  ether  seldom  causes  disturbances  of  the  circulation,  and 
hence  does  not  so  frequently  kill  by  sudden  paralysis  of  the  heart.  Burns 
and  Holz  showed  by  means  of  the  tachometer  that  inhalations  of  ether  cause 
an  increase  in  the  strength  of  the  pulse,  while  chloroform,  on  the  other  hand, 
weakens  it.  Angelesco  and  others  claim  that  ether,  by  producing  dilatation 
of  the  vessels,  lowei-s  the  body  temperature  more  than  cliloroform.  which 
causes  a  contraction  of  the  vessels.  Ether  has  no  injurious  effect  upon  the 
blood  either  by  lowering  the  percentage  of  ha?moglobin  or  destroying  the 
red  blood-corpuscles.  The  number  of  white  corpuscles  is  increased,  and  this 
leucocytosis  reaches  its  maximum  some  hours  after  the  narcosis  (Leuber) 
The  mucous  membranes  are  irritated  by  ether,  and  their  secretions  are 
increased.  Most  of  the  statistics  regarding  the  mortality  of  ether  and  chloro- 
form show  that  ether  is  less  dangerous  than  chloroform.  Among  forty  thou- 
sand etherisations  at  the  Hotel-Dieu  in  Lyons,  there  was  not  a  single  fatal 
case.  Poppert  is  the  only  one  who  has  claimed  a  high  mortality  for  ether. 
He  included  the  cases  that  died  some  time  later,  pai'ticularly  from  pneumonia, 
twenty-fom'  to  thu'ty-two  hours  after  the  operation.  He  found  that  there 
was  one  death  to  every  1.167  etherisations,  and  for  chloroform  one  death  ta 
2,64:7.  It  should  be  said,  in  reply  to  this,  that  all  ana?sthetics  wruld  show 
a  much  higher  mortality  if  we  considered  the  cases  that  died  twenty-four 
to  thirty-six  hours  after  the  operation,  and  it  is  often  diSicult  to  say  how 
much  the  anaesthesia  is  responsible  for  the  later  deaths.  Furthermore,  the 
pneumonias  that  follow  the  use  of  ether  can  be  easily  prevented  if  the 
anaesthetic  is  admini.stered  properly,  and  hence  the  drug  should  not  be  made' 
responsible  when  the  fault  lies  in  the  way  it  is  given.  In  ray  opinion  our 
present  statistics  do  not  give  us  any  reliable  data  regarding  the  danger  from 
the  use  of  ether  and  chloroform.  Both  drugs  have  then'  dangei-s.  and  the  fatal 
cases  are  much  more  common  than  the  statistics  show,  as  they  are  so  often 
not  reported.  For  the  mortality  of  the  different  anaesthetics  as  shown  by  the 
statistics  of  the  Deutsche  Gesellschaft  fiir  Chirui-gie  see  page  31. 

The  typical  mode  of  death  from  ether  is  primary  arrest  of  respiration 
and  secondary  paralysis  of  the  heart.  Ether  gives  rise  more  fi'equently  than 
chloroform  to  later  disturbances,  particularly  in  the  lungs  Hjronchitis, 
broncho-pneumonia,  inflammatory  oedema  of  the  lungs  1,  which  often  come 
on  two  to  thi-ee  days  afterwards,  and  may  or  may  not  prove  fatal.  It  is 
important  from  this  point  of  view  to  use  pure  ether  which  has  not  been 
decomposed  by  au'  or  light.     The  addition  of  air  even  without  the  action  of 


§  14]  ETHER  NARCOSIS.  41 

light  can  easily  give  rise  to  decomposition  products  (oxidation,  formation  of 
aldehyde),  which  irritate  the  air-passages  and  cause  pulmonary  inflamma- 
tion. I  keep  the  ether  that  is  used  for  anEesthesia  in  small  dark  bottles,  con- 
taining about  150  cubic  centimetres,  which  are  kept  filled,  protected  from 
the  light,  and  stored  in  a  cool  place.  Since  I  have  used  only  pure  ether 
with  no  decomposition  products,  I  have  not  observed  any  signs  of  irritation 
within  the  air-passages.  According  to  Nauwerk,  G-rossmann,  and  Holicher, 
ether  pneumonias  are,  generally  speaking,  due  to  unskilful  etherisation — i.  e. 
they  are  caused  by  aspiration  of  mucus  which  is  filled  with  bacteria.  As 
a  matter  of  fact,  one  should  prevent  the  saliva  from  collecting  in  too  large 
amounts,  and  the  patient's  head  should  be  lowered,  in  order  that  the  mucus 
may  not  be  aspirated  into  the  bronchi.  Ether  should  not  be  used  at  all  in 
diseases  of  the  respiratory  passages  and  in  teething  children.  Furthermore, 
ether  should  not  be  employed  when  the  thermo-cautery  is  to  be  used  about 
the  face  and  neck,  nor  in  protracted  operations  about  the  mouth,  jaw,  nose, 
or  throat,  when  the  mouth  and  nose  have  to  be  kept  uncovered.  If  in  the 
latter  case  the  etherisation  has  to  be  interrupted  too  early  or  too  often,  a 
complete  narcosis  can  not  be  obtained.  For  this  reason  chloroform  is  better 
for  long  operations  on  the  face  and  neck.  Sanger  and  Quercain  have  drawn, 
attention  to  the  possibility  of  haemorrhages  in  old  people  in  consequence  of 
the  increased  arterial  pressure.  The  assertion  that  ether  more  frequently 
gives  rise  to  nephritis  or  albuminuria  has  been  shown  to  be  incorrect  (see 
page  35).  The  statistics  regarding  the  frequency  of  the  transitory  albumi- 
nuria following  the  use  of  ether  show  a  variation  with  the  different  anaes- 
thetics of  from  10  to  47.6  per  cent.  In  the  case  of  chloroform  they  vary 
from  38.06  to  SO  per  cent.  Chloroform  seems  to  be  more  harmful  to  the  kid- 
neys than  ether  (Babacci  and  Bebi).  Thomsen  and  Kemp,  however,  claim 
that  their  reseai'ches  show  the  opposite.  Both  chloroform  and  ether  should 
be  used  with  great  caution  in  diseases  of  the  kidney,  as  nephritis  that  is  al- 
ready present  is  made  worse  by  both  drugs. 

The  manifestations  of  ether  narcosis  resemble  those  of  chloroform 
narcosis,  but  the  action  of  the  drug  is  not  so  lasting.  During  ether 
narcosis  the  great  amount  of  saliva  secreted  is  troublesome,  stertorous 
breathing  often  occurs,  and  not  infrequently  a  thick  white  foam  issues 
from  the  mouth  and  nose.  As  the  result  of  the  dilatation  of  the 
cutaneous  vessels,  an  increased  warmth,  redness,  and  cyanosis  occur. 
At  times  a  transitory  exanthema  in  the  form  of  broad,  roseola-like 
spots,  makes  its  appearance,  soon  after  the  beginning  of  the  etherisa- 
tion, in  the  region  of  the  neck  and  chest.  Finally,  mention  should  be 
made  of  the  great  inflammability  of  this  drug — a  circumstance  which 
increases  the  difiiculty  of  giving  it  at  night  or  in  operations  where  the 
galvano- cautery  or  thermo-cautery  is  to  be  used.  Kappeler  relates 
the  case  of  an  eighteen-year-old  girl,  in  Lyons,  who  was  etherised  in 
order  to  apply  the  cautery.  Suddenly,  as  the  surgeon  was  about  to 
use  the  cautery  on  his  patient,  the  ether  vapour  ignited,  setting  fire  to 
the  cone  filled  with  ether  which  was  beino-  held  over  her  mouth  and 


42  THE  ALLEVIATION  OF   PAIN   DURING   OPERATIONS. 

nose,  and  tlie  face  of  the  patient  became  enveloped  in  flames.  Ter- 
rible burns,  involving  the  tissues  down  to  the  bone,  were  the  result  of 
this  accident,  and  the  surgeon,  in  his  efforts  to  extinguish  the  flames, 
sustained  no  inconsiderable  injuries. 

The  other  consequences  of  ether  narcosis — the  nausea  and  vomiting 
— are  the  same  as  in  chloroform  narcosis.  Sometimes,  as  already  men- 
tioned, there  have  been  observed  bronchitis,  broncho-pneumonia,  dis- 
turbances of  respii-ation  (asphyxia,  Cheyne-Stokes  breathing),  and  a 
collapselike  condition,  especially  after  prolonged  operations.  The  col- 
lapse from  ether  may,  however,  be  a  result  of  the  cooling  off  of  the  sur- 
face of  the  body.  The  disturbances  on  the  part  of  the  respii-atory 
organs  may  not  disappear  until  two  to  three  days  after  the  operation. 
The  largest  amount  of  ether  has  usually  left  the  body  one  hour  after 
completion  of  the  aneesthesia.  The  patient  sometimes  remains  asleej> 
for  an  unusually  long  time  afterwards,  while  hysterical  patients  may 
become  very  restless  and  excited. 

On  account  of  the  great  volatility  of  ether  a  special  mask  or  cone 
is  necessary  for  administering  the  same.  There  are  a  large  number  of 
cones  in  use. 

Clover's  consists  of  three  closely  connected  parts — a  metal  vessel  to 
hold  the  ether,  a  rubber  bag,  and  a  mouthpiece.  The  lower  half  of 
the  metal  vessel  is  surrounded  by  a  water  tank  closed  by  a  screw  valve, 


Fig.  81. — Juillard-Dumont's  ether-cone.  Fig.  82. —  Wanscher's  ether-cone. 

the  tank  being  intended  to  keep  the  ether  from  cooling  off  too  much. 
Dumont's  modification  of  Juillard's  mask  consists  of  two  metal  frames 
placed  one  over  the  other  and  connected  by  a  hinge,  the  outer  one 
being  covered  with  oilcloth.    Between  the  two  frames  is  placed  a  piece 


§14.] 


ETHER  NARCOSIS. 


43 


wire  frame- 1 
work. 


Ether. 


Fig.  33. — Grossmann's  ether-cone. 


of  cloth  or  flannel.     The  mask  is  large,  and  coYers  the  whole  face. 
Over  it  is  placed  a  folded  towel  to  prevent  the  evaporation  of  the  ether. 

Wanscher's  apparatus  is  shown  in  Fig.  32.  It  consists  of  a  cone 
and  a  rubber  bag  for  taking  up  the  ether  vapour.  Grossmann  has  modi- 
fled  this  apparatus  by  inserting  a  wire  frame,  so  that  the  rubber  bag 
does  not  collapse  (Fig.  33).  Gehles's 
apparatus  can  be  folded  together  and 
easily  carried  in  the  coat  pocket.  Just 
as  in  the  case  of  chloroform,  apparatus 
have  been  constructed  which  make  it 
possible  to  give  the  patient  a  specifled 
mixture  of  ether  vapour  and  air  (Dreser 
and  others).  In  order  not  to  be  dis- 
turbed by  the  cone  during  operations 
on  the  face,  we  can  insert  a  rubber  tube 
into  the  mouth  or  nose,  and  connect  it 
vdth  Junker's  or  Kocher's  apparatus. 

The  same  precautions  are  necessary 
in  etherising  as  in  giving  chloroform. 
In  adults  I  inject  0.01  to  0.03  morphine 

liypodermically  from  ten  to  twenty  minutes  before  beginning  the  ether. 
The  patient's  head  should  be  inclined  somewhat  backwards,  in  order 
that  the  increased  amount  of  saliva  may  not  flow  into  the  air-passages 
and  give  rise  to  aspiration  pneumonia.  For  the  same  reason  one  should 
prevent  the  mucus  from  collecting  in  too  large  amounts  in  the  mouth 
and  throat  by  swabbing  out  the  same  at  frequent  intervals.  The  ad- 
ministration of  ether  should  be  "  pushed  "  more  than  is  customary  with 
chloroform,  since  it  acts  less  powerfully.  In  using  Juillard's  cone,  for 
example,  considerable  ether  should  be  poured  on  at  first  (30  to  50  cubic 
centimetres,  for  instance),  and  it  is  usually  possible  to  obtain  complete 
anaesthesia  with  this  amount,  particularly  in  children.  Dreser  has 
examined  the  mixture  of  air  and  ether  under  Juillard's  cone  during 
etherisation,  and  determined  that  there  is  neither  an  alarming  accumu- 
lation of  carbonic  acid  nor  a  dangerously  small  percentage  of  oxygen. 
Other  surgeons  prefer  a  more  gradual  way  of  giving  the  ether  to  this 
asphyxiating  method — i.  e.,  the  cone  is  brought  near  the  face  more 
gradually,  and  the  amount  of  ether  given  is  slowly  increased.  In  some 
individuals  this  method  is  undoubtedly  preferable.  The  respiration  is 
the  chief  thing  to  be  watched  in  giving  ether,  but  the  pulse  should  not 
be  neglected.  If  the  respiration  suddenly  stops  in  consequence  of 
paralysis  of  the  respiratory  centre  from  too  much  ether,  the  latter 
should  be  stopped  at  once  and  artificial  respiration  begun.     The  latter 


44  THE   ALLEVIATION   OP   PAIN   DURING   OPERATIONS. 

is  usually  successful  if  the  disturbance  in  breathing  is  noticed  promptly. 
In  case  also  of  spasm  of  the  respiratory  muscles,  causing  the  face  to 
become  very  blue,  the  ether  should  be  temporarily  discontinued. 

A  subsequent  stage  often  follows  the  real  anaesthesia,  in  which  the 
loss  of  sensation  continues,  but  the  patient  has  returned  to  conscious- 
ness. The  same  thing  occurs  in  the  use  of  bromethyl  (see  page  47). 
For  the  treatment  of  the  disturbances  following  etherisation  (vomiting, 
etc.),  see  page  29,  Chloroform  Anaesthesia. 

Action  of  Ether  on  the  Laryngeal  Muscles.— Semen  and  Horsley  have 
coufirmed  by  their  experiments  the  observatious  made  by  others,  namely, 
that  the  posterior  crico-arytajnoid  muscles  are  the  first  to  lose  their  power  of 
contraction  after  death  and  in  cases  of  organic  disease  or  injury  to  the  cen- 
tres or  to  the  branches  of  the  motor  nerves  of  the  larynx. 

In  deep  ether  narcosis  thei'e  is  abduction  of  the  vocal  cords :  and  when  the 
narcosis  is  slight  there  is  adduction,  no  matter  whether  the  recurrent  laryn- 
geal nerve  is  divided  or  not. 

Narcosis  per  Rectum. — Molliere  and  Iversen  have  successfully  produced 
ether  narcosis  by  introducing  the  vapour  into  the  rectum  by  means  of  a 
rubber  tube  connected  with  Richardson's  ether  vapouriser.  Molliei'e  also 
passed  into  the  rectum  a  rubber  tube  which  was  connected  with  an  ether 
flask  standing  in  water  at  50°  C.  (112°  F.),  thus  causing  the  ether  to  boil. 
Molliere  mentions  as  advantages  of  rectal  anaesthesia  the  lack  of  a  stage  of 
excitement,  the  possibility  of  exactly  regulating  the  amount  of  ether  given, 
and  the  convenience  of  the  method  in  operations  on  the  face. 

Rectal  etherisation  was  first  used  by  PirogoflF  forty  years  ago.  Recently, 
Starcke  has  also  investigated  the  method  and  has  urged  its  further  trial. 

The  other  compounds  of  ethyl  have  not  become  established  as  anaesthetics  ; 
among  them  are  ethyl  chloride,  ethyl  bromide,  ethyl  nitrate,  ethylidene 
chloride,  ethyl  aldehyde  or  aldehyde,  Allan's  ether,  acetic  ether,  etc. 

§  15.  Laughing-Gas  Narcosis. — Among  the  inorganic  compounds, 
nitrogen  monoxide  or  laughing  gas  (Davy),  is  the  best  anjesthetic. 
Nitrous  oxide,  N"20,  is  a  colourless  gas  with  a  slightly  sweetish  taste 
and  smell.  It  is  made  by  cautiously  heating  ammonium  nitrate,  which 
breaks  up  at  a  temperature  of  170°  C.  into  water  and  nitrous  oxide. 
The  aneesthetic  action  of  laughing  gas  is  not  unpleasant,  and  there  are 
almost  no  disagreeable  after-effects  ;  nausea  and  vomiting  scarcely  ever 
occur.  But  it  is  not  entirely  free  from  danger,  though  it  is  much  less 
dangerous  than  chloroform  or  ether.  Statistics  show  that  out  of  four 
to  five  million  cases  where  it  has  been  used,  only  fourteen  deaths  have 
been  recorded  (E.  H.  Hankel).  In  a  few  instances  it  has  caused  epi- 
leptic fits,  great  excitement,  deep  cyanosis,  and  similar  phenomena,  but 
in  general  the  drug  is  relatively  free  from  danger.  After  making  in- 
vestigations with  the  spectroscope,  Ulbrich  came  to  the  conclusion  that 
nitrous  oxide  formed  a  chemical  combination  with  the  heemoglobia, 


§  16.]  MIXED  NARCOSIS  AND   OTHER  ANAESTHETICS.  45 

and  so  could  become  dangerous  ;  •  but  Prejer,  Buxton,  MacMunn,  and 
Rothmann  were  unable  to  confirm  these  statements  of  Ulbrieh's,  as  the 
duration  of  the  narcosis  is  too  short,  therefore  these  authors  consider 
that  nitrons  oxide  is  not  a  dangerous  angesthetic.  Still,  a  narcosis  of 
long  duration  is  not  to  be  recommended.  The  drug  is  suitable  for 
short  operations,  particularly  the  extraction  of  teeth,  and  hence  laugh- 
ing gas  is  to-day  the  best  anaesthetic  for  the  dentist,  and  in  England 
and  America  it  is  used  with  very  great  frequency.  In  fifty  to  sixty 
seconds  the  anaesthesia  is  so  complete  that  minor  operations,  like  the 
extraction  of  teeth,  can  be  performed  without  pain.  Kecovery  from 
the  narcosis  is  equally  prompt,  and  without  unpleasant  after-effects. 
Laughing  gas  has  also  been  frequently  used  during  parturition,  and 
with  good  results  (Zweifel).  The  gas  is  inhaled  either  pure  or  mixed 
with  air.  For  the  sake  of  economy  the  gas  is  now  stored  in  a  gasom- 
eter or  rubber  bag  so  arranged  that  the  expired  gas  can  be  used 
over  again. 

Narcosis  with  Oxygenated  Laughing  Gas.— Klikowitsch,  Doderlein, 
Schreiter,  and  Hillischer  have  recommended  an  oxyg-enated  nitrous  oxide 
(nitrous  oxide  with  twenty  per  cent,  oxygen)  for  narcosis  instead  of  the  pure 
nitrous  oxide.  It  is  suited  especially  for  protracted  narcosis  in  which  major 
surgical  operations  can  be  performed.  The  two  gases  are  stored  in  two  sepa- 
rate gasometers  and.  are  mixed  immediately  before  inspiration.  The  appara- 
tus is  so  arranged  that  the  proportion  of  the  mixture  can  he  altered  at  any 
moment. 

Narcosis  with  Oxygenated  Laughing  Gas  and  Increased  Atmospheric 
Pressure. — P.  Bert  has  recommended  the  administration  of  a  mixture  of 
nitrous  oxide  with  fifty  per  cent,  of  air  under  increased  atmospheric  pressure 
(two  to  three  atmospheres).  With  nitrous-oxide  narcosis  conducted  under 
these  conditions  of  inci'eased  atmospheric  pressure,  the  operator,  his  assistants, 
and  the  patient  must  enter  a  specially  prepared  room,  where  the  air  can  be 
compressed  and  the  patient  inhale  the  nitrous  oxide.  This  atmosphere  of 
compressed  air  is  said  not  to  be  very  disagreeable  for  the  operator  and  his 
assistants. 

The  advantages  claimed  for  nitrous-oxide  narcosis  with  compressed  air 
are :  1.  The  absence  of  a  stage  of  excitement.  3.  The  ease  of  maintaining 
for  a  long  time  any  desired  degree  of  narcosis.  3.  The  prompt  return  of 
consciousness.  4.  The  absence  of  vomiting.  5.  The  complete  freedom  from 
danger.     For  combined  laughing-gas  and  ether  anaesthesia  see  below. 

Other  Anaesthetics. — The  other  inorganic  compounds  which  have  been 
tried  as  anaesthetics,  such  as  nitrogen,  carbonic  acid,  bisulphide  of  carbon, 
etc.,  should  be  abandoned. 

§  16.  Mixed  Narcosis  and  other  Anaesthetics. — The  above-mentioned 
anaesthetics  have  been  frequently  mixed  with  each  other.  The  Yienna 
school  recommends  a  mixture  of  three  parts  ether  and  one  part  chloro- 
form.    Linhart  used  a  mixture  of  four  parts  chloroform  and  one  part 


46  THE   ALLEVIATION   OF   PAIN   DURING  OPERATIONS. 

absolute  alcohol.  Billroth  favours  a  mixture  of  three  parts  chloroform, 
one  part  ether,  and  one  part  absolute  alcohol.  The  English  Commit- 
tee on  Chloroform  has  tried  three  different  mixtures :  1.  One  part- 
chloroform  and  four  parts  ether.  2.  One  part  chloroform  and  two 
parts  ether.  3.  One  part  alcohol,  two  parts  chloroform,  and  three 
parts  ether. 

The  first  mixture  acts  like  unmixed  ether,  while  the  other  two  are 
almost  the  same,  and,  while  inducing  a  speedy  loss  of  consciousness, 
interfere  less  with  the  functions  of  the  heart  than  does  pure  chloro- 
form. I  once  used  almost  exclusively  a  mixture  of  one  hundred  parts 
chloroform,  thirty  parts  ether,  and  twenty  parts  absolute  alcohol.  At 
present  I  prefer  a  mixture  of  equal  parts  of  chloroform  and  ether. 

Different  authors  have  recommended  a  mixture  of  oxygen  with 
chloroform,  ether,  or  laughing  gas,  etc.  Many  surgeons  combine  the 
chloroform  and  ether  narcosis,  beginning  the  narcosis  with  chloroform 
and  keeping  it  up  with  ether,  or  vice  versa.  I  use  the  chloroform- 
ether  narcosis  a  great  deal  in  adults,  and  am  well  satisfied  with  it.  A 
combination  of  laughing  gas  and  ether  is  now  being  used.  This  does 
away  with  the  stage  of  excitement  and  the  irritating  action  of  the 
ether.  Laughing  gas  is  used  first,  and  then  ether  is  substituted.  Very 
rapid  anaesthesia  is  said  to  be  produced  by  using  first  bromethyl  and 
then  chloroform. 

Morphine-Chloroform  Narcosis. — The  morphine-chloroform  narcosis 
— a  combination  first  tried  by  Kussbaum — is  of  considerable  value.  It 
is  especially  suitable  for  alcoholic  cases,  and  for  individuals  in  whom  a 
well-marked  stage  of  excitement  is  to  be  expected.  One,  two,  or  three 
centigrammes  of  acetate  of  morphine  are  given  in  aqueous  solution, 
hypodermically,  about  ten  to  twenty  minutes  before  the  narcosis  is 
begun,  or  immediately  preceding  the  latter ;  afterwards,  a  second  in- 
jection may  be  given  during  the  stage  of  excitement,  or  later  in  the 
progress  of  the  narcosis,  particularly  if  the  operation  is  protracted. 
The  advantages  of  a  mixed  morphine -chloroform  narcosis  (which  I 
only  use  on  adults)  are  as  follows :  The  narcosis  progresses  more 
quickly  and  quietly ;  there  is  less  mental  worry ;  the  stage  of  excite- 
ment is  shortened,  or  completely  absent ;  the  respiration  is  more  regu- 
lar, and  a  smaller  amount  of  chloroform  is  required.  It  is  possible  in 
this  morphine-chloroform  narcosis  to  render  the  patient  insensible  to 
the  pain  of  the  operation,  while  the  reflexes  are  retained,  as  well  as 
control  of  the  voluntary  muscles,  and  the  patient  remains  in  full  pos- 
session of  his  senses ;  he  hears  and  answers  any  questions  which  may 
be  put  to  him.  This  state  of  narcosis  is  very  valuable  for  operations 
on.  the  face,  mouth,  pharynx,  and  nose,  as  the  patient  will,  when  told 


§  16.]  MIXED  NARCOSIS  AND   OTHER  ANESTHETICS.  47 

to,  eject  the  blood  collecting  in  his  mouth,  or  swallow  it,  as  the  reflex 
excitability  of  the  muscles  of  the  pharynx  and  palate  is  not  lost.  If 
it  is  desired  to  obtain  this  condition  of  semiansesthesia,  one  and  a 
half  or  two  centigrammes  of  acetate  of  morphine  should  be  injected 
about  ten  minutes  before  the  narcosis  is  begun,  after  which  the  patient 
should  be  chloroformed  till  the  stage  of  excitement  is  reached,  and  then 
the  amount  of  chloroform  administered  should  be  gradually  diminished. 

As  objections  to  the  combined  morphine-chloroform  narcosis,  I 
have  noticed  that  the  morphine  sleep  following  the  operation  has  a  bad 
influence  upon  breathing,  and  sometimes  permits  the  inhalation  of 
foreign  matter  with  a  resulting  aspiration  pneumonia. 

Langlois  and  Maurange  combine  chloroform  with  oxysparteine. 
Three  to  four  centigrammes  of  oxysparteine  with  one  centigramme  of 
morphine  are  injected  a  quarter  of  an  hour  before  beginning  the  chloro- 
form. The  narcosis  comes  on  promptly,  can  be  kept  up  by  the  use  of 
very  little  chloroform,  and  the  heart's  action  is  very  regular. 

Instead  of  injecting  morphine  subcutaneously,  two  to  four  grammes 
of  chloral  hydrate  can  be  given  by  mouth  some  time  before  the  opera- 
tion. This  chloral-chloroform  narcosis  resembles  quite  closely  the 
morphine-chloroform  narcosis. 

Other  surgeons  inject  morphine,  atropine,  and  chloral — e.  g.,  a  hypo- 
dermic syringeful,  containing  2  centigrammes  of  morphine,  -^  milli- 
gramme of  atropine,  and  1  centigramme  of  chloral.  Frankel  injects, 
one  quarter  of  an  hour  before  beginning  the  chloroform,  1  to  1^  cubic 
centimetre  of  a  solution  containing  morphine,  0.15 ;  atropine,  0.015 ;. 
chloral  hydrate,  0.25  ;  distilled  water,  15.0.  Morphine  is  supposed  to 
act  as  a  stimulant  to  the  heart,  and  atropine  upon  the  respiration. 

In  ether  anaesthesia,  also,  I  inject  0.01  to  0.03  morphine  from  ten 
to  twenty  minutes  before  beginning  the  anaesthetic,  and  find  it  a  very 
good  combination. 

Ore,  Deiieppe,  and  Van  Wetter  have  repeatedly  produced  anaesthesia  by 
injecting-  chloral  hydrate  into  a  vein,  but  this  is  entirely  too  dangerous  to  be 
made  use  of. 

Other  Anaesthetics. — Acetal. — Recently  Von  Mering  has  tested  the  anaes- 
thetic powers  of  acetal,  and  particularly  dimethylacetal  and  diethylacetal. 
He  strong-ly  recommends  a  mixture  consisting  of  two  volumes  of  dimethyl- 
acetal and  one  volume  of  chloroform  as  being  less  dangerous  than  chloro- 
form, since  it  has  less  of  the  paralysing  effect  on  the  heart's  action.  Liicke 
states  that  the  narcosis  induced  by  dimethylacetal  and  chloroform  has  no 
marked  stage  of  excitement,  and  only  exceptionally  causes  vomiting. 

Bromethyl. — Inhalations  of  bromethyl  are  sometimes  used  in  operations 
of  short  duration,  such  as  extraction  of  teeth.  It  is  just  as  dangerous  as  the 
other  anaesthetics.  Gurlt  estimates  the  mortality  at  1  to  5,228  ;  and  Borscha 
1  to  20,000.     According  to  Gilles  the  fatal  cases,  which  result  usually  from 


48  THE  ALLEVIATION   OP   PAIN   DURING  OPERATIONS. 

cardiac  paralysis,  are  due  to  the  use  of  uu  impure  prei)aration,  or  too  large  a 
dose,  or  to  the  employment  of  bromethylene  by  mistake. 

Bromethyl  (ethyl  bromate),  bi'omate  of  ether,  CaHeBr,  is  a  colourless 
liquid  smelling  like  ether  and  having  a  neutral  reaction.  It  is  neither 
inflauunable  nor  explosive,  but  evaporates  very  rapidly  wiieu  expo.sed  to  the 
air.  Only  chemically  pure  bi'omethyl  should  be  used  for  narcosis,  and 
hence  it  sliould  be  tested  beforeliand.  When  pure  bromethyl  is  poured  on 
the  hand  it  immediately  evaporates  without  leaving  a  greasy  feeling.  On 
tlie  addition  of  one  per  cent,  nitrate  of  silver  to  an  impure  preparation  a 
cloudiness  appears,  which  in  a  short  time  becomes  milk  white  (Pomeranzer). 
The  method  of  conducting  the  narcosis  with  this  drug  is  the  same  as  with 
ether  and  chloroform,  and  I  have  used  it  with  success  in  short  operations- 
extraction  of  teeth,  etc.       , 

Bromethyl  acts  better  when  access  of  air  is  prevented  as  far  as  possible 
by  laying  a  piece  of  folded  cloth  or  compress  over  the  inhalation  mask,  or, 
still  better,  by  using  the  Juillard-Dumont  ether  mask  with  its  oilcloth  cover. 
In  children  ten  to  fifteen  grammes  and,  in  adults  ten  to  thirty  grammes,  are 
necessary  to  produce  the  narcosis,  which  usually  comes  on  in  about  one  half 
to  one  and  a  half  minutes  and  lasts  one  and  a  half  to  three  minutes,  and  is 
seldom  followed  by  disagreeable  after- eflPects,  though  I  have  several  times 
seen  vomiting.  During  the  next  two  or  three  days  the  breath  has  an  un- 
pleasant smell  of  garlic. 

The  use  of  bromethyl  in  conjunction  with  chloroform  has  been  recom- 
mended by  a  number  of  surgeons.  Bromethyl  is  used  first,  and  then  chloro- 
form. The  narcosis  is  said  to  take  place  quickly,  and  often  without  excite- 
ment. The  patient  comes  out  of  the  anaesthesia  promptly,  and  there  are  no 
subsequent  disturbances. 

Ethyl  Chloride. — Soulier  and  Ludwig  recommend  ethyl  chloride 
("Kelen")  for  short  operations.  It  was  used  sixty-six  times  in  Hacker's 
clinic. 

Bromethylene  should  be  entirely  rejected.  Szuman  observed  a  fatal  in- 
stance of  its  use  in  a  man  twenty-seven  years  old,  who  was  given  by  mistake 
thirty  grammes  of  bromethylene  instead  of  bromethyl. 

Bromoform. — Von  Horoch  has  studied  the  anaesthetic  eflFect  of  bromo- 
form,  but  the  results  obtained  do  not,  as  yet,  seem  to  justify  its  use  in 
surgery. 

Peji^aZ.— Amylene,  w^hich  has  been  recently  given  the  name  of  pental 
(CsHio)  by  C.  A.  Kahlbaum,  has  been  much  used  for  narcosis  in  short  oper- 
ations. The  method  of  its  administration  is  the  same  as  that  of  chloroform, 
and  anaesthesia  occurs  in  from  fifty  to  ninety  seconds.  It  has  no  influence 
on  the  heart  and  respiration,  and  the  patient  regains  consciousness  in  three 
or  four  minutes,  while  sensation  remains  lost  for  several  minutes  longer. 
Pental  is  inflammable,  like  ether.  Eecent  experience  with  it  shows  that  it  is 
not  to  be  recommended  as  an  antesthetic.  Asphyxia,  syncope,  albuminuria, 
and  haimoglobinuria  have  been  observed,  and  a  number  of  deaths  have 
occurred. 

Narcosis  resulting  from  Irritation  of  the  Laryngeal  Mucous  Membrane.— 
Brown-Sequard  made  some  very  interesting  investigations  which  show  that 
general  anaesthesia  may  follow  irritation  of  the  laryngeal  mucous  membrane 


§  17.]  LOCAL   ANAESTHESIA.  49 

with  carbonic  acid  and  chloroform,  and  he  amputated  the  thigh  of  a  rabbit 
in  this  way  without  pain.  The  irritation  of  the  laryngeal  mucous  membrane 
is  the  essential  thing ;  after  division  of  the  superior  laryngeal  nerve  anaes- 
thesia does  not  occur.  If  the  superior  laryngeal  nerve  on  only  one  side  is 
cut,  and  the  carbonic  acid  or  chloroform  is  then  applied,  there  results  simply 
a  slight  diminution  of  sensation  on  this  side,  while  upon  the  other  there  is  a 
condition  of  complete  or  partial  anaesthesia ;  on  one  side  a  toe  could  be  ampu- 
tated without  the  least  pain,  but  on  the  other  side  the  operation  caused  the 
most  violent  manifestations  of  pain. 

§  17.  Local  Anaesthesia. —For  producing  local  anaesthesia  of  a  par- 
ticular part  of  the  body,  the  methods  are  :  compression,  cold,  electricity 
with  or  without  the  addition  of  a  narcotic,  and,  above  all,  the  local 
application  of  certain  drugs.  Frequently,  in  former  times,  the  vessels 
and  nerves  of  an  extremity  were  tightly  compressed  by  a  tourniquet, 
which  caused  a  local  though  certainly  insufficient  anaesthesia.  Cold  is 
also  a  good  local  anaesthetic.  James  Arnott  was  the  first  to  employ  a 
freezing  mixture  of  ice  and  salt ;  but  since  1866  Richardson's  ether 
spray  has  come  into  much  more  general  use,  and  is  far  more  con- 
venient. 

The  ether  is  sprayed  over  some  particular  spot  on  the  skin  for  one 
or  two  minutes,  causing  the  skin  to  become  first  red,  then,  as  the  evap- 
oration of  the  ether  produces  cold  (—  15°  C),  it  becomes  white,  parch- 
mentlike, and  without  feeling.  But  the  loss  of  sensation  is  principally 
limited  to  the  skin.  This  method  is  suitable  for  small  operations — 
opening  abscesses,  puncturing  cysts,  and  for  operations  on  the  extrem- 
ities after  the  latter  have  been  tied  off  with  a  tight  elastic  tourniquet. 
By  the  use  of  a  fan  the  anaesthesia  is  hastened,  and  by  interrupting  the 
circulation  the  freezing  of  the  tissues  is  favoured,  bobbin's  prepara- 
tion of  ether,  which  is  practically  methylene  bichloride,  works  better 
than  the  ordinary  sulphuric  ether.  The  attempt  to  perform  major 
ojDerations  under  ether  spray  has  not  proved  very  successful. 

Ethyl  chloride  is  used  as  a  substitute  for  ether  in  the  freezing 
method ;  but  it  cannot  very  well  be  employed  on  an  open  wound,  as  it 
is  excessively  painful. 

A  spray  of  methyl  chloride  is  used  in  the  same  way  as  the  ether 
spray,  especially  in  France. 

Cocaine. — At  present  we  have  in  cocaine  a  most  excellent  local 
anaesthetic,  which  was  first  used  in  ophthalmology  by  Koller.  Solu- 
tions of  cocaine  easily  become  mouldy,  and  hence  they  should  be  pre- 
pared in  small  quantities,  and  some  bichloride  of  mercury  or  carbolic 
acid  added.  It  is  best  to  have  the  solution  freshly  prepared,  or  at 
most  two  to  three  days  old.  The  intensity  and  duration  of  the  anaes- 
thetic action  can  be  increased  by  neutralising  the  freshly  prepared 
5 


50  THE  ALLEVIATION   OF   PAIX   DURING   OPERATIONS. 

solution  by  the  addition  of  carbonate  of  soda,  and  warming  it  to  5(i°  to 
55°  C,  or  by  giving  a  hypodermic  injection  of  mor[)hine  a  quarter 
of  an  hour  before  using  the  cocaine.  For  operations  on  mucous  mem- 
branes aqueous  solutions  of  five  to  twenty  per  cent,  are  used.  It  is 
dropped  into  the  conjunctival  sac,  and  painted  upon  other  mucous 
membranes.  In  operations  on  the  external  integument  5  to  15  milli- 
grammes are  injected  into  and  beneath  the  skin,  I  use  for  this  pur- 
pose a  weak  solution  (one  per  cent.),  and  inject  from  one  to  ten 
syringefuls,  depending  upon  the  case.  The  injections  can  be  made 
under  ether  spray,  and,  in  case  of  the  extremities,  elastic  constriction  is 
employed.  A  distinction  is  made  between  direct  and  regionary  local 
angesthesia.  In  direct  anaesthesia  the  injection  is  made  at  the  point 
where  the  cut  is  to  be  made,  while  in  regionary  anaesthesia  it  is  made 
at  some  distant  point  along  the  main  sensory  nerve.  Kegionary  co- 
caine anaesthesia  is  only  successful  in  those  places  where  the  blood 
supply  can  be  cut  off  and  the  peripheral  sensory  nerve  anastomoses 
can  be  excluded.  This  is  mainly  true  of  the  fingers  and  toes.  Ke- 
gionary anaesthesia  is  produced  as  follows :  The  base  of  the  finger 
or  toe  is  tied  off  with  a  piece  of  rubber  tubing  and  a  one-per-cent.  solu- 
tion of  cocaine  is  injected  close  to  the  constricted  point  and  in  the 
direction  of  the  tip  of  the  finger  or  toe.  Complete  anaesthesia  requires 
from  three  to  six  minutes  and  sometimes  longer,  and  hence  one  should 
wait  that  length  of  time  before  beginning  the  operation.  In  direet 
anaesthesia  loss  of  sensation  usually  takes  place  immediately.  Region- 
ary cocaine  anaesthesia  can  also  be  employed  on  the  hand  and  foot,  but 
it  is  necessary  to  wait  a  somewhat  longer  time  before  beginning  the 
operation.  The  anaesthetic  effects  of  cocaine  last  from  ten  to  twenty 
minutes. 

Cocaine  is  not  free  fi'om  danger,  and  should  hence  be  employed 
with  great  care.  Symptoms  of  poisoning  frequently  occur,  consisting 
of  dizziness,  excitement,  unconsciousness,  convulsions,  and  pallor  of  the 
face,  with  a  weak  and  rapid  pulse.  Death  has  occurred  in  not  a  few 
cases,  even  after  the  injection  of  cocaine  into  the  ureters  for  facilitat- 
ing catheterisation.  Weigand  has  collected  two  hundred  and  fifty 
cases  of  acute  cocaine  poisoning,  vrith  twenty-one  deaths.  The  most 
dangerous  method  of  employing  it  is  to  apply  a  large  amount  of  a 
strong  solution  to  mucous  membranes.  Subcutaneous  injections,  par- 
ticularly by  the  regionary  method,  are  much  less  dangerous.  Among 
twenty-one  fatal  cases,  seven  occurred  from  its  internal  administration 
and  two  after  its  application  within  the  rectum.  To  prevent  fainting 
and  other  cerebral  manifestations  it  is  important  for  the  patient  to 
maintain  a  recumbent  position  during  and  immediately  after  the  oper- 


§  ir.]  LOCAL  ANAESTHESIA.  51 

ation.  Death  is  usually  due  to  tlie  employment  of  too  large  an  amount 
of  a  strong  solution.  In  the  great  majority  of  fatal  cases  the  amount  of 
cocaine  injected  into  the  skin  was  more  than  twenty-two  centigrammes. 
According  to  Maurel,  the  poisonous  action  of  cocaine  is  due  to  contrac- 
tion of  the  small  vessels  and  the  emboli  that  result  therefrom.  The 
maximum  dose  has  been  put  at  three  centigrammes.  Wolfler  considers 
that  the  maximum  dose  for  injection  about  the  head  should  be  two 
centigrammes,  and  for  the  extremities  five  centigrammes.  It  seems  to 
me  impossible  to  fix  a  maximum  dose  for  cocaine,  as  so  many  individ- 
uals are  very  susceptible  to  it,  while  others  can  take  large  doses  with- 
out any  bad  symptoms.  The  best  antidote  for  cocaine  poisoning  is 
amyl  nitrite  in  the  form  of  inhalations,  which  should  be  given  at  the 
first  signs  of  cerebral  angemia  (Feinberg).  Bromide  of  potassium, 
morphine,  and  antipyrine  have  also  been  used  with  advantage.  Gau- 
tier  has  not  seen  any  symptoms  of  poisoning  since  he  began  to  add 
nitroglycerin  to  the  cocaine.  He  uses  the  following  solution :  Co- 
caine, 0.2 ;  aq.  distillata,  10 ;  1  per  cent,  nitroglycerin,  gtt.,  x. 

Schleich's  Infiltration  Anaesthesia.— Quite  recently  Schleich's  infiltration 
anaesthesia,  which  is  absolutely  without  danger,  has  come  more  and  more 
into  general  use.  It  is  possible  to  perform  with  it  operations  of  considerable 
magnitude,  such  as  laparotomies  (gastrostomies,  etc.),  and  operations  on  the 
joints  of  half  an  hour's  duration.  I  have  not  found  it  so  efficient  in  inflam- 
matory tissues.  The  method  consists  briefly  in  rendering  the  tissues  to  be 
operated  on  bloodless  (ischtemic) — i.  e.,  insensitive — by  injection  of  a  mor- 
phine-cocaine solution.  On  the  extremities  the  parts  may,  in  addition,  be 
rendered  bloodless  by  an  Esmarch  bandage ;  but  this  should  not  be  done 
until  after  the  solution  has  been  injected,  because  otherwise  the  blood  can- 
not be  forced  out  of  the  tissues  by  the  aueesthetising  fluid,  and  the  injection 
is  painful  on  account  of  the  great  tension  of  the  tissues.  Schleich  has  recom- 
mended three  different  sohitions  :  Solution  I :  Cocaine,  0.2  ;  morphine,  0.025  ; 
sodium  chloride,  0.2 ;  aq.  distillata,  100.  Solution  II  contains  half  as  much 
cocaine  as  solution  I.  Solution  III  contains  one  tenth  as  much  cocaine  as 
solution  I,  and  only  0.005  morphine.  Solution  II  usually  suffices.  The 
injections  are  made  under  the  strictest  asepsis  and  with  a  proper  needle 
(Schleich's  or  Braun's).  The  first  injection  causes  the  formation  of  a  tense 
white  wheal,  and  the  needle  is  reinserted  on  the  edge  of  this  wheal,  and  so 
on.  The  subjacent  tissues  are  then  made  anaesthetic  by  injecting  them  at 
once,  or  after  making  the  incision  through  the  skin.  Braun  recommends 
the  following  solution  for  Schleich's  anaesthesia  :  0.1  eucaine  B  (see  page  52)  ; 
0.8  sodium  chloride  ;  and  100  water  at  body  temperature.  As  much  as  three 
hundred  cubic  centimetres  of  this  solution  can  be  injected  at  one  operation. 
It  is  not  decomposed  by  repeated  boilings.  G-eneral  anaesthesia  with  Schleich's 
mixture  (consisting  of  chloroform,  ethyl  chloride,  and  ether  in  the  different 
proportions)  has  not  met  with  general  favour.  For  the  fingers  and  toes  the 
method  of  cocainisation  combined  with  elastic  constriction  is  distinctly  pref- 
erable to  Schleich's   method.      One  disadvantage  of  the  latter  is  that  the 


52  THE   ALLEVIATION   OF   PAIN   DURING   OPERATIONS. 

topographical  relations  are  sometimes  distui'bed  bj'  the  oedema,  and  the  bor- 
der line  between  the  liealthy  and  diseased  tissues  may  be  indistinct. 

Cocaine  in  Conjunction  with  the  Galvanic  Current. — Wagner  and  Herzog 
have  ana?sthetised  tlie  unbroken  skin  with  cocaine  in  conjunction  with  the 
galvanic  current.  The  anode,  previously  dipped  in  a  cocaine  solution,  is 
placed  upon  the  skin  a  certain  distance  from  the  cathode,  and,  after  the  cur- 
rent has  been  turned  on,  the  portion  of  the  skin  lying  between  the  electrodes 
becomes  anaesthetised.  The  strength  of  the  current  was  two  to  four  milli- 
amperes.  The  method  depends  upon  the  cataphoric  action  of  the  current  in 
moving  fluids  from  the  anode  to  the  cathode. 

Cocaine  with  Ethyl  Chloride. — E.  Nagy  has  good  results  from  the  use  of 
cocaine  in  combination  Avith  ethyl  chloride  for  the  extraction  of  teeth  (one 
third  to  one  half  a  syriugeful  of  a  freshly  prepared  two-per-ceut.  solution  of 
cocaine).  The  gum  is  sprayed  with  the  ethyl  chloride  for  about  a  minute 
after  the  injection  of  cocaine,  until  a  thick  layer  of  white  crystals  forms. 

Other  Anaesthetics  possessing  a  Local  Action. — The  local  application  of 
chloroform,  opium,  saponin,  amylene,  carbon  bisulphide,  etc.,  or  the  use  of 
the  constant  or  induced  current  in  combination  with  chloroform,  tincture  of 
aconite,  the  alcoholic  extract  of  aconite,  etc.,  have  all  been  found  to  be  of 
little  value.  On  the  other  hand,  I  have  had  good  success  with  menthol  (in 
combination  with  lanolin  or  olive  oil).  Menthol  is  not  a  dangerous  drug, 
and  a  whole  hypodermic  syringeful  of  a  ten-  to  twenty-per-cent.  solution  of 
menthol  in  olive  oil  can  be  injected  into  and  under  the  skin.  The  ether 
spray  may  be  combined  with  it.  The  local  application  of  a  mixture  of  equal 
parts  of  menthol  and  lanolin  has  also  been  found  efficacious. 

As  a  substitute  for  cocaine,  Claiborne  has  recommended  stenocarpin  in  a 
two-per-cent.  solution.     It  is  a  very  expensive  alkaloid. 

Erythrophlaeine  has  been  used  as  a  local  ansesthetic,  but  is  of  slight  value. 
Reid  recommends  drumine,  an  alkaloid  from  euphoi'bia.  Vamossy  uses 
anasin  (aqueous  solution  of  acetone-chloroform),  which  in  a  one-per-cent. 
aqueous  solution  corresponds  in  action  to  2  to  2.5  per-cent.  cocaine.  Eucaine 
is  employed  a  good  deal  in  solutions  of  two  to  ten  per  cent.  Two  grammes 
can  be  injected  at  one  time  without  hai'm.  The  advantages  of  eucaine  over 
cocaine  are  said  to  be  that  it  is  less  poisonous,  cheaper,  more  stable,  and  can 
be  sterilised,  as  the  solutions  are  not  decomposed  by  heat.  It  does  not  act 
like  cocaine,  by  producing  anaemia  of  the  tissues,  but,  on  the  contrary,  pro- 
duces hyperajmia.  I  do  not  find  it  so  efficient  in  preventing  pain  as  cocaine. 
Braun  recommends  eucaine  for  infiltration  ansesthesia. 


CHAPTEE   III. 

THE  PEEVENTION    OF    LOSS    OF    BLOOD   DURING  AIST  OPERATIOlSr. — ESMAECh's 

ARTIFICIAL    ISCHEMIA. 

The  prevention  of  loss  of  blood  in  all  operations. — Different  niethocls :  Digital  com- 
pression of  the  main  artery ;  tourniquets ;  ligation,  or  "  Umstechung,"  tearing, 
tying-oflf,  or  clamping  of  adhesions  or  of  blood-vessels  before  they  are  divided. — 
Esmarch's  artificial  ischaemia  in  operations  on  the  extremities:  its  technique;  its 
advantages  and  disadvantages. — Modifications  of  Esmarch's  method. — The  appli- 
cation of  the  method  to  various  parts  of  the  body. — Historical. 

§  18.  The  Prevention  of  Loss  of  Blood  during  an  Operation. — In  all 

operations  we  must  bear  in  mind  the  necessity  of  making  the  loss  of 
blood  as  small  as  possible,  particularly  in  the  case  of  weak  or  anemic 
individuals,  in  children  less  than  a  year  old,  and  in  the  aged.  If  this 
rule  is  not  taken  to  heart  many  a  patient  will  perish  simply  from  loss 
of  blood. 

The  modern  surgeon  has  many  ways  of  saving  blood  during  an 
operation.  Frequently  the  artery  supplying  the  part  in  question  is 
ligated  before  the  operation  is  begun,  as,  for  instance,  both  lingual 
arteries  in  removal  of  a  cancerous  tongue ;  or  the  artery  is  compressed 
by  the  finger  only  while  the  operation  lasts  (digital  comjDression)  • 
again,  in  some  cases,  the  vessel  may  be  secured  by  a  suture  passed 
through  the  skin  and  under  the  vessel  (percutaneous  ligation  en  masse). 

In  the  extirpation  of  new  growths  and  tumours  connected  to  the 
surrounding  parts  by  vascular  and  more  or  less  strong  adhesions,  the 
vessels,  or  the  vascular  adhesions,  are  seized  by  self -locking  pincers  or 
artery  clamps,  and  the  vessels,  or  vascular  strips  of  tissue,  after  being 
secured  by  two  clamps,  or  a  double  ligature  of  silk  or  catgut,  are 
divided  between  them. 

This  procedure  is  much  facilitated  by  tearing  through  the  weak, 
non-vascular  attachments,  which  yield  readily  to  the  pressure  of  the 
finger,  while  the  stronger  and  more  vascular  parts  resist,  and  can  be 
felt  and  more  readily  recognised. 

Lacerated  wounds  bleed  less  than  incised  ones.  If  a  large  vessel  is 
wounded,  the  bleeding  from  it  is  at  once  stopped  by  the  pressure  of 

53 


54  THE  PREVENTION  OF  LOSS  OF  BLOOD  DURING  AN  OPERATION. 

the  finger,  and  the  vessel  is  then  seized  by  an  artery  clamp  and  divided 
between  a  double  ligature,  one  of  which  closes  the  central  and  the 
other  the  peripheral  open  end  of  the  vessel.  In  other  cases,  to  pre- 
vent loss  of  blood,  the  cautery  iron  or  galvano-cautery  is  used,  etc. 
The  technique  of  this  method  is  mentioned  later  (§  25). 

§  19.  Esmarch's  Artificial  Ischaemia. — The  bloodless  method  of  oper- 
ating on  the  extremities  has  been  perfected  by  the  ingenuity  of  Es- 
march.  In  removing  an  extremity  by  Esmarch's  method,  not  only  do 
we  save  the  blood  in  the  limb  to  be  amputated,  but  also,  during  the 
operation,  bleeding  is  almost  entirely  prevented  by  the  elastic  constric- 
tion of  the  Hmb  previously  made  anoemic.  The  so-called  tourniquet 
(Fig.  3-1)  was  formerly  used  to  check  the  flow  of  blood  during  amputa- 
tions, or  the  same  end  was  attained  by  compressing  the  main  artery  of 
the  part  with  the  fingers  (digital  compression).     (Figs.  35,  36.) 

At  the  present  time,  for  rendering  operations  on  the  extremities 
bloodless,  we  use  Esmarch's  very  simple  and  efficacious  method,  which 
consists  in  tying  off  the  member  after  it  has  first  been  emptied  of 


Fig.  34.— Petit's  screw 
tourniquet. 


Fig.  35. — Digital  compression 
of  the  femoral  arterv. 


Fig.  Sfi. — Digital  compression 
of  the  brachial  arterv. 


blood.     The  old-fashioned  tourniquets  and  digital  compression  have 
been  abandoned  for  this. 

Suppose,  for  instance,  that  we  wish  to  perform  an  amputation  of 
the  leg.  After  the  leg  has  been  propei'ly  disinfected  and  shaved,  it  is 
first  elevated  and  then  wrapped  in  a  sterilised  elastic  bandage  drawn 
moderately  tight,  from  the  toes  upward  as  far  as  the  lower  third  of 
the  thigh.  The  end  of  the  bandage  is  then  held  by  an  assistant,  or 
after  the  last  turn  the  roll  is  tucked  under  the  immediately  preced- 
ing turn.  The  bandage  should  have  been  previously  disinfected  by 
immersion  in  a  solution  of  one  tenth  per  cent,  bichloride  or  of  three 


§  19.] 


ESMARCH'S  ARTIFICIAL  ISCH.EMIA. 


55 


to  four  per  cent,  carbolic.  To  avoid  forcing  into  the  lymph  channels 
any  noxious  materials,  such  as  tumour  germs  or  pus,  etc.,  the  diseased 
part  should  not  be  covered  by  the  wrappings,  but  carefully  avoided ; 


FiQ.  37. — Esmarch's  rubber 
tubing  for  producing 
artificial  ischtemia. 


Fig.  38. — Clamp  for  the  rubber 
tubing  used  for  producing 
artificial  ischsemia. 


Fig.  39.— Fixation  of  Es- 
march's rubber  tubing 
by  means  of  the  clamp. 


or,  better  still,  the  elastic  bandage  should  in  such  instances  not  be 
used  at  all. 

Finally,  Esmarch's  rubber  tourniquet  is  wound  moderately  tight 
around  the  limb  at  the  upper  termination  of  the  elastic  bandage,  and 
the  latter  is  removed.  In  case  the  elastic  bandage  is  not  used,  the 
extremity  is  held  vertically  for  a  couple  of  minutes  and  stroked  lightly 
from  above  downward  to  diminish  the  amount  of  venous  blood,  and 
then  the  rubber  tourniquet  is  applied.  Fig.  37  illustrates  the  usual 
form  of  Esmarch's  elastic  tourniquet,  with  a  chain  and  hook  for  fas- 
tening it. 

Another  way  of  securing  the  tourniquet  is  illustrated  in  Figs.  38 
.and  39.  The  two  ends  of  the  rubber  tube  are  inserted  in  a  so-called 
"  tube  clamp,"  which  consists  of  a  half-open  brass  ring  fastened  to  a 
plate.  The  ends  of  the  tube  are  well  stretched  and  forced  into  the 
slot,  and  when  relaxed  the  ends  are  held  tightly  pressed  together  (Fig. 
39).  In  place  of  the  rubber  tubing  used  as  a  tourniquet  one  can  sub- 
stitute a  piece  of  linen  previously  sterilised  and  moistened.  Thus  the 
extremity  is  emptied  of  blood  up  to  the  lower  third  of  the  thigh,  and 
the  leg  can  be  amputated  as  on  the  cadaver. 

At  the  conclusion  of  the  amputation  the  principal  arteries  and  veins 
are  clamped  and  tied.  This  is  quickly  done,  as  the  vessels  can  be  easily 
seen  in  the  bloodless  stump.  The  larger  muscular  branches  of  the 
arteries  will  be  found  at  the  point  where  the  connective-tissue  sheaths 
which  envelop  the  different  bundles  of  muscles  cross  each  other. 
When  all  the  visible  vessels  have  been  secured  in  the  bloodless  stump 
the  latter  is  elevated,  and  its  surface  compressed  with  two  or  three 


56  THE  PREVENTION  OP  LOSS  OF  BLOOD  DURING  AN  OPERATION. 

aseptic  sponges  or  compresses,  while  an  assistant  slowly  loosens  the 
Esmarch  tourniquet,  but  is  ever  on  the  alert  to  tighten  it  again  if 
bleeding  should  occur  at  any  point.  After  removal  of  the  tourniquet 
the  hitherto  apparently  dead  extremity  becomes  bright  red.  At  the 
same  time,  unless  the  stump  is  elevated  perpendicularly  and  the  wound 
compressed  for  a  couple  of  minutes,  there  almost  always  follows  cov.- 
siderable  oozing,  because  the  pressure  of  the  elastic  tourniquet  produces 
a  temporary  vasomotor  paralysis  which  prevents  the  smaller,  unsecured 
vessels  from  contracting  and  closing  spontaneously. 

When  Esmarch's  method  first  came  into  general  use  this  oozing 
was  thought  by  many  surgeons  to  be  such  a  serious  matter  as  almost  to 
outweigh  the  advantages  of  the  method,  and  others  held  that  the  loss 
of  blood  during  the  oozing  which  followed  was  greater  than  in  the  case 
of  the  old  methods.  Ice-water  irrigations,  the  application  of  the  elec- 
tric current,  injections  of  ergot  into  the  tissues  around  the  wound,  etc., 
were  all  practised  to  prevent  this  oozing. 

I  have  always  been  perfectly  satisfied  with  elevating  the  stump  and 
making  pressure  on  the  wound  for  a  couple  of  minutes  with  sponges 
or  compresses,  and  after  doing  this  I  have  never  seen  any  subsequent 
oozing  worth  mentioning,  and  the  patient  loses  really  only  a  few  drojjs 
of  blood. 

Esmarch  recommended  that  drains  be  put  in  place,  and  the  wound 
sutured  and  dressed  antiseptically  before  removing  tlie  elastic  tourni- 
quet. This  can  be  done  in  suitable  cases — for  instance,  in  necrosis 
operations  or  extirpation  of  tumours.  I  never  adopt  it  in  amputations 
and  resections,  but  always  check  the  bleeding  first.  "Whichever  plan 
is  adopted,  the  extremity  which  has  been  operated  upon  should,  after 
the  dressings  have  been  applied,  be  invariably  placed  in  an  elevated 
position  for  the  next  twenty -four  hours,  as  by  this  means  the  oozing 
will  be  minimised. 

This  elevation  of  the  stump  has  also  an  antiphlogistic  and  analgesic 
effect,  and  therefore  can  be  used  with  great  advantage  in  various  forms 
of  inflammatory  processes  on  the  extremities.  When  the  extremities 
are  elevated  there  is  regularly  a  diminution  in  the  height  of  their  tem- 
perature. According  to  Meule,  for  an  elevation  lasting  sixty  minutes, 
the  maximum  diminution  is  7.2°  C.  (12.9°  F.),  the  minimum  2°  C. 
(3.6°  F.),  Furthermore,  the  blood  pressure  is  lessened,  and  the  fre- 
quency of  the  pulse  averages  a  decrease  of  nine  beats  to  the  minute. 
Upon  this  also  depends  the  hsemostatic  power  of  elevation. 

The  advantages  of  Esmarch's  method  consist  in  the  actual  saving 
of  blood  and  in  the  possibility  of  operating  in  a  dry  wound  without 
the  need  of  sponges.     Moreover,  fewer  assistants  are  required,  and 


§  19.]  ESMARCH'S   ARTIFICIAL   ISCHEMIA.  57 

everything  can  be  plainly  seen — a  matter  of  much  importance  in 
searching  for  a  small  foreign  body,  like  a  needle  point,  or  for  a  wound 
in  a  blood-vessel.  Furthermore,  Esmarch's  elastic-tube  tourniquet  can 
be  applied  to  any  part  of  the  extremities,  which  was  not  the  case  with 
the  old-fashioned  appliances. 

The  method  has  really  no  serious  disadvantages.  It  has  been  shown 
how  easy  it  is  to  stop  the  oozing  which  follows  removal  of  the  elastic 
tourniquet  and  which  has  been  found  fault  with  by  so  many  surgeons, 
and  I  do  not  yet  consider  it  proved  that  the  edges  of  wounds,  for  in- 
stance, in  amputations,  become  more  often  necrotic  after  using  Es- 
march's method  (Konig).  Sometimes  there  has  been  observed  a  pare- 
sis of  the  nerve  trunks  of  shorter  or  longer  duration,  especially  after 
tight  constriction  of  the  arm,  and  in  exceptional  cases  cutaneous  flaps 
have  died  from  want  of  nourishment.  But  these  mishaps  are  not  to 
be  ascribed  to  the  method,  but  to  its  unskilful  application — i.  e.,  to  too 
much  compression. 

The  Increased  Power  of  Absorption  possessed  by  the  Tissues  after  Re- 
moval of  the  Elastic  Tourniq[uet.  —  Wolfler  experimented  on  dogs  with 
potassium  ferrocyanide,  cyanide  of  potassium,  strychnine,  etc.,  to  determine 
whether,  in  a  limb  rendered  anaemic  by  Esmarch's  method,  absor-ption  occurs 
up  to  the  point  of  application  of  the  rubber  tubing-,  and  how  the  absorption 
is  affected  by  removal  of  the  constriction.  It  appeared  that  while  the  elastic 
tourniquet  remained  in  place  no  absorption  occurred,  but  that  after  it  was 
removed  absorption  was  very  much  accelerated.  Therefore  Wolfier  recom- 
mends that  the  constriction  be  maintained  until  the  wound  has  been  dressed 
antiseptically  and  elevated.  All  moistening  of  the  wound  with  such  poison- 
ous substances  as  carbolic  acid,  bichloride  of  mercury,  and  the  like,  should 
be  done  before  the  removal  of  the  elastic  tourniquet. 

Autotransfasion.— After  great  losses  of  blood,  which  endanger  life,  Es- 
march's bandage  may  be  applied  to  the  extremities  in  order  to  force  the  blood 
in  the  latter  towards  the  heart,  and  so  avert  a  threatened  heart  failure  or 
cerebral  anaemia  (so-called  autotransfusion). 

For  how  long  a  time  can  EsmarcKs  constriction  ie  hept  up 
with  impunity  f — At  present  this  question  cannot  be  satisfactorily 
answered.  Esmarch  has  maintained  his  artificial  anaemia  on  human 
limbs  for  two  hours  and  a  quarter  without  doing  any  damage.  If  the 
constriction  is  kept  up  for  three  to  four  hours,  the  vitality  of  the 
tissues  cut  off  from  the  circulation  may  be  imperilled.  The  results  of 
animal  experimentation  cannot  be  applied  to  man,  and  therefore  I 
shall  omit  a  discussion  of  the  same. 

The  following  is  a  brief  summary  of  the  technique  for  applying 
Esmarch's  constriction  to  particular  parts  of  the  body.  The  method  of 
using  Esmarch's  elastic  tourniquet  on  the  shoulder  for  high  amputation 


58     THE  PREVENTION  OP  LOSS  OP  BLOOD  DURING  AN  OPERATION. 

of  the  arm,  or  for  removal  of  the  arm  at  the  shoulder  joint,  is  illustrated 
in  Fig.  40,  a  and  h.  The  Esinarch  elastic  tourniquet  cannot  be  used 
for  disarticulation  of  the  arm — e.g.,  for  a  large  tumour — because  here 


Fig.  40. — Esmarch's  tubing  applied  at  the 
shoulder. 


Fig.  41. — Application  of  Esmarch's  rubber 
tubing  about  the  hip. 


the  artery  would  be  compressed  against  the  head  of  the  humerus,  and 
as  soon  as  the  latter  was  freed  from  the  joint  the  tourniquet  would 
be  useless.  Therefore  it  is  better  in  such  a  case  either  to  ligate  the 
subclavian  artery  first  and  then  proceed  with  the  disarticulation,  or  to 
perform  a  high  amputation  of  the  arm,  using  Esmarch's  constricting 


Fig.  42.  Fig.  43.  Fig.  44. 

Figs.  42-44. — Compression  of  the  aorta  (Esinarch). 


rubber  tube,  then  ligate  the  vessels  in  the  stump,  and  finally  remove 
the  remaining  portion  of  the  humerus  subperiosteally.  It  is  manifestly 
not  wise  to  carry  Esmarch's  elastic  tourniquet  around  the  thorax  in  the 


§  19.]  ESMARCH'S   ARTIFICIAL   ISCH.EMIA.  59 

form  of  a  shoulder  spica,  as  the  thorax  would  be  compressed  during 
the  narcosis.  The  manner  of  applying  the  elastic  tourniquet  in  the 
region  of  the  hip,  for  amputation  of  the  thigh,  is  illustrated  in  Fig.  41. 
The  pressure  on  the  femoral  artery  can  be  increased  by  placing  a  cloth 
pad  or  roller  bandage  beneath  the  elastic  tube  over  the  artery.  For 
amputation  of  the  hip  joint,  Esmarch  recommends  compression  of  the 
aorta  after  having  previously  emptied  the  intestines  (Figs.  42  to  44). 
The  following  plan  (Yolkmann's)  is  better :  After  applying  the  rubber 
bandage  tightly  up  to  the  inguinal  region,  the  elastic  tom-niquet  is  car- 
ried from  the  femoro-scrotal  commissure  in  the  direction  of  Pou23art's 
ligament  obliquely  outward  to  the  semilunar  notch  of  the  ilium  be- 
tween its  two  anterior  spines.  During  the  operation  the  tube  is  held 
in  the  hands  of  an  assistant,  or,  better  still,  it  is  secured  in  position  by 
three  pieces  of  bandage  tied  around  it  and  drawn  upward  to  prevent  it 
slipping  down  after  division  of  the  muscles.  Another  way  is  to  apply 
the  rubber  tubing  about  the  thigh  and  pelvis  (Fig.  41),  perform  a  high 
amputation  of  the  thigh,  arrest  the  haemorrhage  in  the  stump,  and  then 
remove  the  stump  of  bone  through  a  longitudinal  incision  over  the 
trochanter.  Esmarch's  artificial  ischsemia,  combined  with  local  anaes- 
thesia, is  excellent  for  small  operations  on  the  fingers  and  toes.  In 
operations  on  the  male  genitals  Esmarch  winds  a  small  rubber  tube 
around  the  base  of  the  scrotum  and  penis,  and,  crossing  its  ends  over 
the  mons  Yeneris,  he  carries  them  around  behind  and  ties  them  together 
over  the  sacrum.  But  I  do  not  consider  the  tournic|uet  necessary,  par- 
ticularly in  amputation  of  the  penis,  where  compression  of  the  part 
with  the  fingers  is  sufficient. 

Langenbeck  has  also  used  Esmarch's  method  in  operations  on  the 
scalp.  The  head  is  first  wrapped  in  a  gauze  bandage,  according  to  the 
rules  for  applying  the  "  Mitra  Hippocratis "  (see  §  50,  Bandaging) ; 
then  the  rubber  bandage  is  passed  around  the  forehead  and  occiput 
and  the  gauze  bandage  cut  off. 

History  of  Artificial  Anaemia.— Constriction  of  an  extremity  above  the 
point  of  amputation  was  much  used  long  before  the  invention  of  the  tourni- 
quet by  Morell  and  J.  L.  Petit,  and  Ambroise  Pare  practised  the  method  in 
the  sixteenth  century.  Even  artificial  anaemia  is  said  to  have  been  used  here 
and  there,  though  never  so  perfectly  as  by  Esmarch.  G-randesso  Siivestri 
appears  to  have  been  the  first  to  envelop  a  limb  with  an  elastic  bandage, 
and,  instead  of  a  tourniquet,  to  have  used  an  elastic  tube.  But  little  notice 
was  taken  of  Silvestri's  proposition,  and  then  Esmarch,  without  knowing 
what  Siivestri  had  done,  continued  the  same  method.  The  honour  of  bring- 
ing artificial  ischsemia  to  its  present  perfection  is  certainly  due  to  Esmarch. 


CPIAPTER  TV. 

GENEKAL   RULES   FOR    PERFORMING   AN    ASEPTIC  OPERATION   AND  FOR  THE 
AFTER-TREATMENT    OF    THE    PATIENT. 

a.  Behaviour  of  the  surgeon  during  the  operation,  h.  Experienced  assistance,  c. 
Close  observance  of  antiseptic  principles,  d.  Asepsis  and  antisepsis,  e.  Acci- 
dents during  the  operation  :  (1)  Syncope ;  (3)  convulsions ;  (3)  haemorrhage.  /. 
Operations  on  "bleeders."  g.  Death  from  entrance  of  air  into  the  veins,  h. 
Death  from  other  causes,  i.  Supplement :  (1)  After-treatment  of  operative  cases ; 
(2)  the  most  important  causes  of  death  after  operation. 

§  20.  Performance  of  an  Aseptic  Operation. — After  the  above-men- 
tioned preparations  for  an  aseptic  operation  have  been  made,  and  the 
patient  has  been  ansestlietised,  every  operation  should  be  performed 
qnicklj,  without  hesitation,  and  with  the  most  scrupulous  regard  to 
antiseptic  precautions.  It  is  not  of  so  much  importance  now  as  it  was 
before  the  introduction  of  anaesthesia  to  perform  an  operation  with 
great  rapidity  in  order  to  spare  the  patient  pain.  Bnt  even  at  the 
present  time  we  perform  operations  as  quickly  as  possible,  because  we 
know  that  an  operation  by  lasting-  for  too  long  a  time  may  prove  fatal 
to  the  patient.  Especially  is  this  true  of  operations  in  the  peritoneal 
cavity,  which  may  prove  fatal  shortly  after  the  operation  because  of 
the  long-continued  loss  of  body  heat  ("Wegner).  The  most  important 
conditions  for  rapid  and  safe  operating  are :  a  careful  examination  of 
the  patient  l)efore  operation ;  a  certain  diagnosis ;  accurate  anatomical 
knowledge  ;  and  a  natural  manual  dexterity.  A  sharp  knife  and  proper 
instruments  scrupulously  clean  are,  of  course,  indispensable. 

As  we  are  fully  conversant  of  the  fact  that  all  wound  diseases  are 
the  result  of  infection  by  bacteria,  and  that  the  life  of  our  patient  may 
be  placed  in  great  danger  if  the  bacteria  enter  the  wound,  we  must 
always  observe  the  strictest  asepsis ;  no  unclean  finger,  no  instrument 
which  has  not  been  previously  disinfected,  must  come  in  contact  with 
the  wound.  The  hands  and  clothing  of  the  operator  and  his  assistants, 
the  instruments,  sponges,  or  gauze  pads,  the  field  of  operation,  etc., 
are  sterilised  after  the  method  described  in  §  6,  and  everything  around 
the  area  to  be  operated  upon  is  covered  with  aseptic  compresses  or 
60 


§31.]  THE   ACCIDENTS  DURING  AN  OPERATION.  Ql 

towels.  Beside  the  operator  and  liis  assistants  there  should  be  suit- 
able basins  for  holding  clean  disinfecting  solutions,  especially  three- 
per-cent.  carbolic  or  1  to  1,000-5,000  bichloride.  Particular  care  must 
be  taken  that  the  wound  is  not  contaminated  directly  or 
indirectly  by  any  spectator's  hands  which  have  not  been 
disinfected — for  instance,  by  allowing  him  to  pass  instru- 
ments, sponges,  etc.  Most  carefully  sterilised  sponges  or 
pads  are  used  to  keep  the  wound  dry,  but  they  should 
bring  nothing  into  the  wound  from  the  surface  surround- 
ing it.  For  operating  upon  the  cavities  in  the  body — 
e.  g.,  the  mouth,  vagina,  etc. — sponge  holders  are  re- 
quired. 

An  excellent  pad  or  sponge  holder  is  illustrated  in 
rig.  45.  By  pushing  up  the  ring  the  jaws  are  closed,  and 
so  firmly  hold  the  sponge  or  pad.  The  use  of  too  con- 
centrated antiseptic  solutions  should  be  avoided,  for  they 
may  cause  dangerous  or  even  fatal  poisoning.  Lister's 
antiseptic  spray  of  three-per-cent.  carboHc  acid  is  no 
longer  used  during  the  operation.  "We  operate  by  the  dry 
method  as  far  as  we  can,  and  should  make  it  our  aim  to 
irritate  the  wound  as  little  as  possible.  ^    ^^^'i^^'i 

^  SpoDge  holder. 

The  beginner  must  learn  gradually,  by  experience,  all 
that  I  have  mentioned ;  what  he  can  learn  from  books  is  not  sufficient. 
When  the  operation  is  finished,  the  fate  of  the  patient  is  practically 
already  settled. 

§  21.  The  Accidents  during  an  Operation. — The  accidents  which  are 
hable  to  occur  during  an  operation  can  be  only  briefly  mentioned  here. 
We  naturally  leave  out  of  account  all  the  numerous  unpleasant  things 
which  may  be  caused  by  the  operator's  error  in  diagnosis,  his  lack  of 
skill  and  judgment,  etc.  The  reader  is  referred  to  my  text-book  on 
Regional  Surgery  for  many  common  accidents  peculiar  to  certain  oper- 
ations— such  as  the  disturbances  which  may  be  caused  by  operations 
on  the  mouth,  air-passages,  and  thoracic  and  peritoneal  cavities. 

Mention  has  been  made  on  pages  29  and  41  of  the  accidents  occur- 
ring during  narcosis.  I  shall  describe  the  other  unfortunate  occurrences 
briefly  as  follows : 

Syncope. — Syncope  occasionally  takes  place,  especially  in  weak  and 
anaemic  individuals,  during  small  operations  performed  without  an 
ansesthetic.  It  either  comes  on  suddenly,  without  warning,  or  it  is  pre- 
ceded by  a  feeling  of  anxiety,  or  a  sinking  feeling  about  the  pit  of  the 
stomach,  or  nausea,  etc.  The  face  becomes  deadly  pale  and  covered 
with  a  cold  sweat,  consciousness  is  lost,  and  the  patient  falls  to  the  floor 


62     GENERAL  RULES  FOR  PERFORMING  AN  ASEPTIC  OPERATION. 

if  stauding,  or  drops  to  one  side  if  lie  is  sitting  in  a  chair.  Sudden 
death  has  been  known  to  occur  in  tliis  way,  as  mentioned  on  page  32. 
During  the  swoon  tlie  sense  of  pain  is  lost. 

Convulsions. — Hysterical  or  alcoholic  individuals  sometimes  have 
convulsions  either  ^vith  or  without  the  syncope.  If  the  cause  of  the 
syncope  is  purely  nervous  the  patient  soon  recovers,  usually  after  a 
few  seconds,  and  seldom  requires  longer  than  two  or  three  minutes. 
If  excessive  loss  of  blood  is  the  cause  of  the  syncope  the  prognosis  is 
of  course  less  favourable.  The  nature  and  treatment  of  this  form  of 
syncope  will  be  taken  np  under  the  subject  of  Wounds. 

The  treatment  of  the  nervous  syncope,  if  I  may  call  it  such,  con- 
sists in  jDlacing  the  patient  in  the  horizontal  position,  sprinkling  the 
face  with  cold  water,  chafing  and  rubbing  the  body  and  soles  of  the 
feet  with  wet  cloths,  giving  stimulants,  camphor,  wine,  ammonia,  also 
plenty  of  fresh  air,  etc. 

Bleeding. — The  dangers  which  arise  from  bleeding  during  an 
operation  are  slight,  as  the  capable  and  careful  surgeon  is  able  to  con- 
trol it  in  a  great  many  ways.  The  treatment  of  bleeding  is  discussed 
in  §§  27-30^ 

An  operation  may  be  complicated  in  a  very  dangerous  way  if  it 
is  undertaken  on  an  individual  of  the  class  of  so-called  bleeders. 


The  "Bleeder  Disease,"  or  Haemopliilia. — The  term  "bleeder  disease,"  or 
hEemophilia,  is  understood  to  mean  a  constitutional  anomaly,  almost  always 

congenital,  which  is 
characterised  by  a  very 
marked  predisposition 
to  bleeding  spontane- 
ously or  as  the  result 
of  some  slight  trau- 
matism. 

Haemophilia  is  gen- 
erally" an  inherited  dis- 
ease, and  occurs  in  so- 
called  bleeder  families, 
in  which  it  is  ti'ans- 
mitted  through  many 
generations,  afflicting 
the  members  in  both 
the  direct  and  indirect 
lines  of  descent.  Los- 
sen  has  investigated  three  generations  of  a  bleeder  family  of  one  hundred 
members  which  took  its  origin  from  healthy  parents ;  seventeen  of  this 
family  were  bleedei's,  and  nine  died  from  excessive  loss  of  blood  (see  Fig.  46)  _ 
The  disease  appears  to  be  more  common  in  the  male  sex — according  to 
Konig,  in  the  proportion  of  one  woman  to  thirteen  men.     Furtherinore,  it  is 


□  O 


□  O 


no  □  o  tJO  nO  n  o  6  liiOOiiQ  QC 


Fig.  46. — Family  tree  (Lessen ).     ■,  Bleeders  (all  males ) ; 
G,  liealthy  males  ;   o.  liealtby  females. 


§21.]  THE  ACCIDENTS  DUEING  AN   OPERATION.  63 

a  fact  that  liEemophilia  is  transmitted  chiefly  through  the  female  members  of 
the  bleeder  family  who  do  not  themselves  suffer  from  the  disease  and  who 
marry  healthy  men.  Moreover,  the  children  of  a  male  haeraophiliac  are  usu- 
ally free  from  the  disease.  In  only  exceptional  cases  this  anomaly  appears 
not  to  be  congenital  but  to  develop  slowly  after  birth. 

The  pathology  of  ha3mophilia  is  still  but  little  understood.  The  cause  of 
the  disease  has  been  ascribed  to  an  abnormal  thinness  of  the  walls  of  the 
vessels,  leading  to  their  easy  rupture  ;  to  their  possessing  too  slight  a  power 
of  contraction,  or  rather  to  a  deficiency  in  the  muscular  coat  of  the  arteries  ; 
to  an  abnormal  blood  pressure  due  to  too  small  a  calibre  in  the  main  arterial 
trunks ;  and,  finally,  to  an  abnormality  in  the  composition  of  the  blood,  mani- 
fested by  imperfect  coagulation.  But  there  is  no  proof  that  any  of  these 
causes  actually  produce  haemophilia,  and  the  microscopical  and  chemical 
examination  of  the  blood  has  hitherto  warranted  no  conclusion  as  to  the  eti- 
ology of  the  disease.  The  blood  usually  coagulates  normally,  though  I  can 
affirm,  in  respect  to  one  case  at  least,  that  the  blood  coagulated  rather  slowly 
and  imperfectly.  Manteuffel  also  found  in  one  case  that  the  blood,  without 
the  addition  of  Schmidt's  ferments,  required  four  and  a  half  minutes  for 
coagulation,  and  with  the  ferments  only  ten  seconds.  I  am  inclined  to 
believe  that  the  composition  of  the  blood  or,  in  other  words,  its  mode  of 
coagulation  is  not  normal  in  haemophilia. 

We  know  that  in  pronounced  leucaemia,  a  disease  of  the  blood  character- 
ised by  the  presence  of  an  excess  of  white  blood-corpuscles,  severe  or  unre- 
strainable  haemorrhage  may  occur.  For  this  reason  surgeons  hesitate  be- 
fore removing  an  enlarged  spleen  in  leucaemia  ;  almost  all  the  patients 
hitherto  operated  upon  have  died  from  haemorrhage.  The  walls  of  the  blood- 
vessels in  a  case  of  haemophilia  j)robably  do  not  possess  the  normal  degree  of 
strength,  and  consequently  are  easily  ruptured  by  the  slightest  traumatism, 
or  even  without  any  known  cause. 

As  to  the  symptomatology  of  haemophilia,  the  haemorrhages  sometimes 
begin  immediately  after  birth — for  instance,  as  an  umbilical  haemorrhage — or 
they  accompany  circumcision  in  Jewish  boys  ;  but  usually  they  make  their 
appearance  later,  at  the  time  of  dentition,  of  shedding  the  milk  teeth,  or  at 
the  age  of  puberty  ;  in  other  words,  at  periods  of  life  when  traumatisms  are  of 
more  frequent  occurrence. 

The  hemorrhages,  usually  parenchymatous  in  nature,  take  their  origin 
from  traumatisms  even  of  the  most  insignificant  kind.  Spontaneous  haemor- 
rhages have  been  observed  without  any  apparent  cause ;  for  instance,  in  and 
under  the  skin  and  mucous  membranes,  or  from  the  stomach,  intestine,  and 
genito-urinary  tract.  But  these  haemorrhages  may  be  caused  by  slight  inju- 
ries of  an  unknown  nature.  At  any  rate,  parenchymatous  haemorrhages  in 
internal  organs  which  are  thoroughly  protected  almost  never  occur. 

The  traumatisms  which  produce  bleeding  in  haemophilia  are  often  of  the 
most  insignificant  kind  ;  for  instance,  a  trifling  pi'essure  on  some  part  of  the 
skin  will  occasion  bleeding  into  and  beneath  this  area ;  brushing  the  teeth 
will  cause  the  gums  to  bleed ;  and  blowing  the  nose  is  often  followed  by  a 
prolonged  nosebleed.  Of  especial  interest  are  the  htemorrhages  into  the 
joints,  producing  a  peculiar  multiple  joint  disorder  (see  Diseases  of  Joints). 
The  bite  of  a  leech  or  an  insect,  the  prick  of  a  needle,  are  not  uncommonly 


64     GENERAL  RULES  FOR  PERFORMING  AN  ASEPTIC  OPERATION. 

followed  by  a  remarkably  profuse  luemorrhage.  Fatal  haemorrhage  has 
been  observed  to  follow  the  extraction  of  a  tooth,  and  when  open  wounds 
are  made  and  operations  are  undertaken  the  result  can  be  imagined.  In  a 
pronounced  case  of  haemophilia  every  method  of  haemostasis  may  be  tried  in 
vain  and  the  patient  will  die  of  haemorrhage.  The  bleeding  may  appear  to 
be  stopped,  but  it  will  recur  again  and  again.  Such  a  state  may  go  on  for 
days,  Aveeks,  and  even  months,  but  it  generally  requires  only  a  few  days  to 
terminate  life. 

Usually,  bleeders  seem  to  possess  a  remarkable  power  of  withstanding  the 
loss  of  blood,  and  not  infrequently  recover  completely  from  very  large  h;i?m- 
orrhages.  One  patient  of  Coates's  lost  twelve  kilogrammes  of  blood  in  eleven 
days.  As  the  subject  of  haemophilia  grows  older  the  intensity  of  his  disease 
seems  to  diminish,  and  in  a  few  instances  it  has  disappeared  entirely. 

The  prognosis  of  haemophilia  depends  upon  the  severity  of  the  disease 
and  the  number  and  kind  of  traumatisms  the  individual  may  be  subject  to. 
Many  sad  cases  go  to  show  that  patients  with  marked  haemophilia  often  do 
not  get  beyond  the  age  of  boyhood,  but  die  quite  young  from  some  trifling- 
wound  or  some  necessary  operation,  or  they  waste  away  with  marked  an;e- 
mia,  which  is  gradually  produced  by  the  constantly  recurring  losses  of  blood 
resulting  from  the  slightest  mechanical  injury.  As  they  get  on  in  years  the 
prognosis  improves,  and  the  disease,  w^hen  rudimentary  in  character,  may 
disappear  altogether. 

Treatment  of  Haemophilia. — In  the  case  of  children  who  come  from 
bleeder  families  or  have  a  marked  tendency  to  bleeding,  prophylaxis  is  very 
important.  Every  means  should  be  taken  to  improve  their  general  condition 
by  good  food  and  aii',  by  frequent  baths,  by  a  careful  toughening  of  the  body, 
etc.,  and  in  this  way  the  disposition  to  bleeding  may  perhai)s  be  checked,  or 
at  least  diminished.  The  rest  of  the  jDrophylactic  treatment  consists  in  pro- 
tecting the  patient,  as  far  as  possible,  from  every  kind  of  traumatism  which 
may  give  rise  to  bleeding.  Any  trifling  mechanical  or  operative  procedure 
— for  instance,  vaccination — should  be  conducted  with  the  utmost  caution  ; 
operations  should  only  be  i)erformed  in  case  of  the  most  extreme  urgency. 
Not  infrequently  bleeders  have  died  of  hamorrhage  after  an  operation,  be- 
cause there  was  no  previous  knowledge  of  their  fatal  peculiarity. 

The  process  of  healing  in  bleeders  is  accompanied  by  peculiar  difficulties, 
which  are  illustrated  by  an  experience  of  Thiersch's,  who  removed  an  en- 
cysted tumour  from  the  face  of  a  bleeder  at  his  urgent  request.  The  wound 
took  six  weeks  to  heal,  and  the  patient  came  near  dying  from  the  complica- 
tions. Thiersch  recommends,  from  his  experience,  that  the  wound  be  not 
sutured,  and  that  compression  dressings  be  discarded. 

Hamorrhage  in  bleeders  is  checked  by  ligation  of  the  bleeding  vessels, 
and  when  necessary  by  the  application  of  a  solution  of  perchloride  of  iron, 
or  the  actual  cautery,  generally  in  the  shape  of  the  Paquelin  instrument.  It 
has  been  mentioned  that  bleeding  is  especially  apt  to  occur  when  the  eschar 
or  thrombus  comes  away,  and  therefore  it  should  be  kept  from  being  dis- 
tui'bed  as  long  as  possible.  Thiersch,  in  his  case,  allowed  the  wound  to  fill 
with  a  blood  clot  and  surrounded  it  with  a  wall  of  compresses  impregnated 
with  ten-per-cent.  salicylic  acid,  and  then  wrapped  the  whole  in  a  thick  layer 
of  carbolised  jute  contained  in  sterilised  gauze  without  applying  any  pres- 


§21.]  THE  ACCIDENTS  DURING  AN   OPERATION.  65 

sure.  lu  this  way  he  avoided  all  pressure,  and  also  prevented  the  clot  from 
becoming'  prematurely  loosened.  On  the  thirty-eig'hth  day  the  clot  came 
away  and  tne  entire  surface  of  the  wound  was  skinned  over. 

ManteufiPel  stopped  the  hsemorrhage  from  an  alveolus  by  cocaine  and 
insertion  of  a  piece  of  cotton  which  was  saturated  alternately  with  Schmidt's 
coagulating  ferment  (zymoplasma)  and  an  aqueous  solution  of  thrombin. 

Henry  Finch,  from  a  successful  experience  with  three  cases,  advises  vene- 
section in  haemophilia  in  conjunction  with  hot- water  irrigation.  By  means 
of  the  latter  the  coagulation  of  the  blood  is  rendered  more  raiDid  and  com- 
plete. Wright  praises  the  internal  administration  of  the  salts  of  lime  prior 
to  operation,  these  salts,  as  is  well  known,  increasing  the  coagulability  of 
the  blood  (see  §  61).  The  internal  treatment  of  haemophilia  by  ergotin,  ace- 
tate of  lead,  laxatives  (Glauber's  salt),  etc.,  is  useless. 

Entrance  of  Air  into  the  Veins.— The  unpleasant  consequences  of  the 
entrance  of  air  into  the  veins  should  receive  special  attention.  It  occurs 
exclusively  after  wounds  of  the  veins  in  the  neighbourhood  of  the  thorax,  or 
more  particularly  of  the  heart;  among  these  veins  are  included  the  axil- 
lary, subclavian,  jugular,  etc.  There  is  scarcely  ever  a  positive  pressure  in 
these  veins,  and  with  every  inspiration  it  becomes  decidedly  negative,  so  thJat 
air  is  sucked  in  when  they  are  wounded — for  instance,  during  an  operation. 
Added  to  this,  the  veins  in  immediate  proximity  to  the  thorax  gape  open 
after  being  wounded,  and  fail  to  collapse  because  they  are  so  closely  attached 
to  the  surrounding  connective  tissue  and  fascia. 

This  is  the  case  with  the  supei'ior  vena  cava,  subclavian,  and  internal 
jugular  veins.  Death  only  takes  place  when  a  large  amount  of  air  is  sucked 
in  at  once  ;  but  single  air  bubbles  are  harmless,  as  they  gradually  disappear 
from  the  blood.  Death  from  the  entrance  of  air  into  the  veins  has  been 
explained  in  various  ways.  According  to  Couty  and  Jiirgensen,  the  air  col- 
lects in  the  right  side  of  the  heart  and  prevents  the  contraction  of  the  right 
ventricle,  causing  the  heart  to  stop  finally  in  diastole.  The  filling  of  the 
right  side  of  the  heart  prevents  the  entrance  of  venous  blood,  thus  stopping 
first  the  pulmonary  and  then  the  whole  arterial  circulation.  According  to 
others— Passet,  for  instance — the  air  passes  from  the  heart  to  the  pulmonary 
arteries,  where  it  is  arrested,  interrupting  the  x^ulmonary  circulation  and 
preventing  the  left  venti-icle  from  filling  with  fresh  blood.  According  to  a 
third  theory,  air  embolisms  in  the  cerebral  arteries  furnish  the  principal 
cause  of  death. 

Recently  Hauer  has  studied  the  subject,  experimenting-  chiefly  on  rabbits, 
and  has  come  to  the  conclusion  that  death  is  principally  the  result  of  air 
embolism  in  the  small  pulmonary  vessels,  and  that  death  can  likewise  be 
caused  by  emboli  in  the  cerebral  vessels,  as  small  air  bubbles  pass  through 
the  pulmonary  circulation  into  the  left  ventricle.  The  introduction  of  air 
into  the  veins  has  long  been  made  use  of  as  a  method  of  producing  death 
experimentally  in  animals.  Rabbits  are  very  sensitive  to  air  in  the  veins, 
while  in  dogs  eight  to  ten  cubic  centimetres  of  air  can  be  injected  into  the 
central  end  of  the  jugular  vein  without  a  fatal  result. 

In  man,  the  aspiration  of  air  into  the  veins  has  hitherto  been  observed 
to  occur  principally  during  operations  in  the  neighbourhood  of  the  thorax 
(region  dangereuse).  Greene  has  collected  sixty-seven  cases  with  twenty- 
6 


6C,     GENERAL  RULES  FOR  PERFORMING  AN  ASEPTIC  OPERATION. 

seven  recoveries,  but  a  larg^e  proportion  of  these  are  ixntrustworthy.  The 
air  is  generally  aspirated  with  an  audible  sucking,  gurgling  sounch  and. in  the 
worst  cases  death  occurs  immediately.  If  the  amount  of  air  taken  in  is 
small,  the  patient  will  recover,  though  Konig  saw  in  such  a  case  great 
anxiety,  with  laboured  breathing  and  dilated  pupils. 

Besides  the  veins  just  mentioned,  wounds  of  other  veins  have  been  knowa 
to  result  fatally  from  aspiration  of  air,  particularly  after  a  very  deep  inspira- 
tion. This  is  true,  for  exaniple,  of  the  dural  sinuses  and  of  the  veins  at  the 
bend  of  the  elbow  during  venesection.  Aspiration  of  air  is  not  possible  in 
the  case  of  the  veins  of  the  lower  extremity.  Spontaneous  aspiration  of  air 
must  not  be  confused  with  injection  of  the  same,  as,  for  example,  in  uterine 
injections.  Injection  of  air  into  the  veins  of  the  uterus  may  also  prove 
fatal. 

Treatment  of  Air  in  the  Veins. — Our  treatment  of  this  condition  amounts 
to  very  little.  By  way  of  prophylaxis,  operations  in  the  neighbourhood  of 
the  great  veins,  particularly  in  the  neck,  should  be  conducted  with  the 
greatest  care.  If  a  large  vein  is  wounded  and  air  is  sucked  in,  the  opening 
in  the  vein  should  be  immediately  stopped  with  the  finger,  especially  during 
inspiration,  and  the  wound  filled  w^ith  an  aseptic  fluid,  perhaps  squeezed 
from  a  sponge,  as  air  only  gets  into  the  vessel  when  the  wound  is  dry. 
Sometimes  the  air  bubbles  are  forced  out  of  the  open  vein  during  expiration, 
and  on  this  account  Fischer  has  suggested  that  vigorous  expiratory  move- 
ments be  made  by  compressing  the  thorax.  The  vein  is  then  to  be  ligated 
as  quickly  as  possible  to  prevent  any  further  entrance  of  air.  If  the  amount 
of  air  that  has  entered  the  vascular  system  is  not  too  great  it  can  be  rapidly 
absorbed  or  eliminated.  The  air  is  eliminated,  according  to  Heller,  more 
quickly  if  the  patient  inhales  a  mixture  of  air  containing  very  little  nitrogen. 
If  a  large  amount  of  air  has  already  been  sucked  into  the  vein  and  has 
reached  the  heart,  further  treatment  is,  of  course,  useless,  for  deatli  in  such- 
cases  is  usually  instantaneous. 

Other  Causes  of  Death  during  an  Operation. — These,  aside  from  the 
cases  of  actual  malpractice,  are  usually  due  to  the  large  amount  of 
blood  lost ;  to  the  particular  kind  of  operation  and  the  lengtli  of  time 
it  takes  ;  to  the  excessive  loss  of  body  heat,  especially  in  operations  in 
the  peritoneal  cavity  ;  and,  finally,  to  the  constitution  of  the  patient. 
These  subjects  are  fully  discussed  in  another  chapter. 

§  22.  The  Post-operative  Treatment  of  Patients. — The  student  is 
referred  to  the  Eegional  Surgery  for  the  after-treatment  of  special 
operative  cases. 

The  general  treatment  of  the  patient  is  very  simple  if,  as  usually 
happens,  the  healing  process  runs  a  normal  course.  After  the  opera- 
tion has  been  performed  and  the  dressing  applied,  the  patient  is  put  to 
bed  and  surrounded,  when  necessary,  with  warm  bottles,  not  too  hot, 
which  are  usually  wrapped  in  flannel  to  prevent  them  from  burning 
the  skin.  The  position  of  the  patient  should  be  as  comfortable  as 
possible,  with  especial  reference  to  the  part  of  the  body  which  has  been 


§23.]    MOST  IMPORTANT  CAUSES  OF  DEATH  AFTER  OPERATION.       67 

operated  upon.  Old  people,  those  suffering  from  emphysema,  etc., 
should  not  have  their  head  and  thorax  placed  too  low,  as  dyspnoea 
or  a  hypostatic  congestion  of  the  lungs  may  easily  occur.  Imme- 
diately after  the  operation  the  symptoms  which  are  the  result  of  the 
narcosis  become  more  or  less  prominent.  For  their  treatment,  see 
page  36. 

It  is  very  important  to  take  the  temperature  two  or  three  times  a 
day  with  a  reliable  thermometer,  and  also  to  keep  run  of  the  pulse. 
Recovery  usually  takes  place  without  fever,  the  latter  being  the  result 
either  of  imperfect  asepsis  during  the  operation  or  of  a  fever  existing 
before  the  operation.  Every  wound  fever  is  caused  by  the  absorption 
of  toxic  substances  from  the  wound  into  the  general  circulation.  The 
so-called  aseptic  wound  fever  (Yolkmann,  Genzmer),  which  probably 
depends  upon  the  absorption  of  blood  or  fibrin  ferment,  is  but  seldom 
seen.  In  general,  it  has  been  my  experience  that  in  all  cases  where 
fever  follows  operation  there  will  be  found  a  corresponding  disturb- 
ance of  the  normal  course  in  the  healing  of  the  wound.  For  the  details 
of  the  nature  and  treatment  of  this  fever,  see  §  62. 

The  greatest  pains,  therefore,  must  be  expended  on  a  careful  super- 
vision of  the  healing  process.  The  dressings  should  be  changed  if  it  is 
called  for  on  account  of  fever,  pain,  or  for  the  removal  of  drainage, 
stitches,  etc.,  or  if  the  dressings  become  loosened,  displaced,  or  satu- 
rated by  the  secretion  from  the  wound.  The  diet  should  be  reduced 
in  quantity,  since  the  need  of  nourishment  is  less  because  of  the  rest  in 
bed  and  the  lack  of  exercise.  Weak  individuals  should  be  given  plenty 
of  wine  and  light,  easily  digestible,  but  strengthening  food.  For 
quieting  the  patient  or  for  allaying  pain,  morphine  should  be  adminis- 
tered in  the  form  of  a  subcutaneous  injection  (0.01  to  0.02  gramme). 
But  morphine  must  be  used  with  caution ;  while  some  individuals  can 
take  very  large  doses  with  impunity,  others  will  manifest  symptoms  of 
poisoning  after  very  small  doses,  l^ext  to  morphine,  the  best  hypnotic 
is  chloral  hydrate  (Liebreich),  two  to  three  to  five  grammes  of  which, 
given  in  a  glass  of  water,  will  usually  induce  sleep  very  quickly.  But 
patients  soon  get  used  to  the  drug,  and  it  then  becomes  more  or  less 
ineffectual  and  may  produce  gastric  irritation.  Of  the  new  hypnotics, 
sulphonal  and  paraldehyde  are  very  good. 

§  23.  The  Most  Important  Causes  of  Death  after  Operation  are  briefly 
as  follows  :  Collapse  ;  shock ;  anaemia  ;  secondary  haemorrhage  ;  poison- 
ing from  the  drugs  used  with  the  dressings,  such  as  iodoform,  carbolic 
acid,  bichloride  of  mercury,  etc. ;  and  particularly  the  wound  diseases 
which  come  from  infection  with  micro-organisms — erysipelas,  pyaemia, 
and  septicaemia,  which  will  be  described  in  their  proper  places. 


68     GENERAL  RULES  FOR  PERFORMING  AN  ASEPTIC  OPERATION. 

AYe  aim  to  prevent  the  infectious  diseases  l)y  the  most  rigid  asepsis 
during  the  oj^eration  ;  to  prevent  poisoning  by  the  cautious  use  of 
antiseptics,  and  secondary  haemorrhage  by  the* most  careful  ligation 
of  bleeding  points  in  the  wound,  AYe  try  to  make  the  amount  of 
blood  lost  during  the  operation  as  small  as  possible  by  the  methods 
described  in  §  18  and  §  19.  The  best  means  to  prevent  an  impend- 
ing collapse  from  haemorrhage  is  the  transfusion  of  delibrinated  blood  ; 
or,  better  still,  of  a  0.6-per-cent.  solution  of  sodium  chloride  into  the 
circulation  or  subcutaneously. 

Recent  experiments  have  demonstrated  that  the  infusion  of  a  0.6- 
per-cent.  solution  of  sodium  chloride  into  the  general  circulation  is,  on 
the  whole,  better  than  transfusion  of  blood.  (For  particulars,  see  §  89.) 
Patients  su:ffering  from  acute  aneemia  should  also  be  given  plenty  to 
drink,  and  wine  especially.  If  collapse  comes  on,  subcutaneous  injec- 
tions of  camphor  (1  to  5  of  olive  oil)  and  ether  should  be  given  with 
the  hypodermic  syringe.  In  severe  cases  this  hypodermic  administra- 
tion of  camphor  and  ether  may  be  repeated  several  times  at  intervals 
of  a  few  minutes. 

Neuroses  following  Operation. — Sometimes  after  operations  neuroses 
of  the  most  varied  sort  will  occur,  especially  hysterical  phenomena, 
melancholia,  nervous  delirium,  etc.  They  are  most  common  in  neuras- 
thenic subjects,  and  repeated  narcoses  may  increase  their  severity  to  a 
marked  degree. 

The  Influence  of  Constitutional  Anomalies  on  the  Healing  of  the 
Wound. — Emphasis  has  justly  been  laid  upon  the  fact  that  the  wound  will 
run  the  normal  course  in  liealing  if  the  operation  has  been  j)erformed  with 
the  most  rigid  observance  of  asepsis. 

But  there  are  chronic  diseases,  constitutional  derangements  in  the  nutri- 
tion of  the  tissues,  which  occasionally  influence  the  course  of  healing  in  the 
wound  (Verneuil,  Paget).  To  this  class  belong  especially  chronic  endarteritis, 
gout,  alcoholism,  syphilis,  Bright's  disease,  diabetes,  scurvy,  malaria,  leucae- 
mia, pernicious  anaemia,  the  morphine  habit,  etc. 

Individuals  suffering  fi'om  chronic  heart  or  kidney  disease  generally 
have  little  power  of  resistance,  and  not  infrequently  collapse  after  a  slight 
and  insignificant  operation.  As  Lloyd  has  remarked,  disease  of  the  kidney 
can  be  so  intensified  by  ether  or  chloroform  narcosis  that  threatening  symp- 
toms of  a  collapselike  nature  may  make  their  appearance.  These  chronic 
diseases  will  sometimes  cause  a  great  retai'dation  in  the  healing  of  the  wound 
made  during  the  operation.  It  is  well  known  how  badly  wounds  heal  in 
persons  afflicted  with  scurvy,  leucaemia,  pernicious  ana3mia,  and  diabetes. 
Operations  should  be  carried  out  with  every  antiseptic  precaution  in  the  case 
of  pregnant  women  ;  while  in  children  less  than  a  year  old,  as  well  as  in  the 
very  aged,  great  care  must  be  taken  to  prevent  unnecessary  loss  of  blood. 


CHAPTER  y. 

■  THE    DIFFERENT    "WAYS    OF    DIVIDING    THE    TISSUES. 

1.  Division  of  soft  parts  (in  which  bleeding  occurs). — The  different  forms  of  knives. — 
The  way  to  hold  the  knife. — Instruments  to  assist  in  the  cutting  (thumb  forceps, 
hooks,  clamps). — Division  of  the  soft  parts  by  scissors. — Perforation  of  soft  parts 
by  puncture  (trocar,  hollow  needle,  hypodermic,  aspirator).  3.  The  so-called 
bloodless  division  of  the  soft  parts  with  the  assistance  of  the  ligature  ;  by  tearing 
the  parts ;  by  compression  ;  by  the  hot  iron,  Paquelin's  thermo-cautery,  or  the 
galvano-cautery. — The  destruction  or  division  of  the  tissues  by  the  use  of  chem- 
icals (caustics).  3.  The  division  of  bones  by  the  chisel,  saw,  bone  forceps,  drill, 
osteoclast,  etc. 

§  24.  The  Division  of  the  Soft  Parts  (accompanied  by  Loss  of  Blood). — 

The  soft  parts  can  be  divided  in  such  a  waj  that  bleeding  may  or  may 


cl  e  f  g 

Fig.  47. — Different  forms  of  knives. 


not  occur.     The  knife  is  the  most  frequently  used  instrument  for  divid- 
ing the  tissues.     The  most  useful  forms  are  illustrated  in  Fig.  47. 

1.  The  scalpel  with  the  blade  immovable  on  the  handle  (Fig.  47,  ci-f). 

2.  Bistoury  for  the  pocket  case.     The  blade  can  be  shut  into  the 

handle  (Fig.  47,  g\ 

69 


70 


THE  DIFFERENT  WAYS  OF  DIVIDING  THE   TISSUES. 


3.  Lancet  (Fig.  47,  h).     This  form  of  knife  is  old-fashioned,  and 
is  l)ut  little  used  at  present,  except  the  so-called  vaccination  lancet  (Fig. 
47,  i).     Its  point  has  a  shallow  groo^•e  for  carrying  lymph 
or  vaccine  virus. 

As  shown  in  the  illustrations,  the  blades  of  the  scalpel 
and  bistoury  have  dilferent  shapes,  some  being  decidedly 
or  slightly  convex,  or  straight  or  curved  to  a  greater  or 
less  degree.  The  tips  of  the  blades  are  also  different, 
some  being  pointed  (Fig.  47,  a-e)  and  others  blunt  (Figs. 
47,/",  and  48).  Many  knives  are  double-edged  or  lance- 
shaped  (Fig.  47,  e).  "We  iise  the  blunt-])ointed  knife  in 
those  cases  in  which  we  wish  to  avoid  injury  to  the  ad- 
joining tissues  by  the  point  of  the  knife.  The  length 
and  breadth  of  the  blade  vary  with  the  kind  of  operation 
in  which  it  is  intended  to  be  used,  the  strongest,  longest, 
and  broadest  knives  being  for  amputations,  disarticulations,  and  joint 
resections.     For   particular   operations   there  are  especially  designed 


Fig.  48.— Blunt- 
pointed  bis 
tourv. 


Fig.  49.- 


-Penholder  method  of  using  the 
knife. 


Fig.  50.— Fiddle-stick  method  of  hold- 
ing the  knife. 


knives.  The  handle  of  the  knife  is  of  wood,  horn,  ivory,  steel,  glass, 
etc.,  and  the  end  is  usually  made  like  a  chisel,  to  facilitate  tearing 
through  the  tissues  when  necessary.  A  nickel-plated  metal  handle  is 
best  adapted  for  the  necessary  sterilisation  of  the 
knife  by  boiling  in  a  one-per-cent,  soda  solution. 

The  usual  ways  of  holding  the  knife  are  illus- 
trated in  Figs.  49-54,  but  I  do  not  lay  down  strict 
rules  when  to  use  this  or  that  method.  Ko  regu- 
lar rules  are  needed  by  any  one  having  a  natural 


Fig.  52.— Method  of  hold- 
ing the  knife  when  the 
tissues  are  divided  from 
within  outwai-ds. 


Fig.  51. — Mt^tliod  of  holding  a  large   knife 
(resection  knife). 


aptitude  for  operating,  or  by  any  one  who  is  familiar  with  dissection. 
Large  knives,  like  those  used  for  resection,  are  held  as  pictured  in 


§34.] 


THE  DIVISION   OF   THE   SOFT   PARTS. 


n 


Pig.  53— Method  of 
holding  a  lai'ge 
amputation  knife. 


Fig.  54. — Method  of  holding  the  lancet. 


Fig.  51.     The  amputation  knife  is  grasped  in  the  closed  fist,  as  in  Fig. 
53.     On  the  other  hand,  the  lancet  is  held  as  indicated  in  Fig.  54. 

The  skin  is  usually  divided  as  follows  :  After  mak- 
ing the  skin  tense  bj  the  thumb,  index,  and  middle 
fingers,  the  incision  is  begun  bj  the  scalpel,  held  in 
the  right  hand,  as  shown  in  Figs.  49,  60,  or  51,  and 
the  blade  is  drawn  between  the  above-named  fingers. 
Or  a  fold  of  skin  is  lifted  up  at  I'ight  angles  to  tlie 

direction  of  the 
intended  incis- 
ion, which  is  then 
carried  down 
through  the  fold. 
If  it  is  desired  to 
make  a  long  in- 
cision at  one 
stroke,  the  knife 
should  be  drawn  rapidlj  along  without  applying  much  pressure. 

"We  frequently  cut  from  within  outwards,  as  in  the  division  of  a 
fistulous  tract,  when  the  knife  is  held  as  in  Fig.  53.  For  this  purpose 
grooved  probes  or  directors  are  commonly  used  (Fig,  55).  In  many 
operations,  as  we  shall  see,  this  di- 
rector is  indispensable,  and  it  is 
especially  valuable  for  the  begin- 
ner. In  such  cases  the  director  is 
pushed  under  the  particular  layer 
of  tissue,  or  into  the  fistulous 
opening,  and  the  point  of  the 
knife,   cutting   edge   uj)wards,  is        , 

pushed  along  in  the  groove,  thus        ill'  \ 

dividing  the  tissues.  The  cutting 
can  be  done  from  in  front  back- 
wards, or  vice  versa,  according  to 
the  case  in  hand.  In  conclusion, 
mention  should  be  made  here  of 
the  ear,  myrtle-leaf,  and  rounded        |i  ^  | 

end  probes  (Fig.  56,  a,  b,  c).  These 
probes  are  generally  used  for  diag- 
nostic purposes,  such  as  exploring 
fistulous  tracts  in  soft  parts  and 

hones,  in  the  search  for  foreign  bodies,  such  as  sequestra,  etc.     Probes 
made  of  silver,  so  that  thev  can  be  bent,  are  the  l)est.     Befoi-e  use. 


Fig.  56. 
Probes. 


m 


Fig.  57. 
Tenotome. 


Y2 


THE  DIFFERENT   WAYS   OF   DIVIDING   THE  TISSUES. 


every  probe  should  be  disinfected  as  carefully  as  possible.     There  will 
be  opportunity  enough  for  warning  against  too  much  probing  of  tis- 


FiG.  58. — Toothed  forceps. 


Fig.  59. — Dressing 
forceps. 


Fig.  60. — Luer's  forceps 
with  a  clasp  on  the  handles.. 


sues,  but  it  is  worth  while  to  give  a  general  caution  on  this  subject 
now.  In  searching  for  foreign  bodies  the  magnetic  needle  has  been 
frequently  used  with  success  (Kocher,  Kalin,  Lauenstein,  Graser,  and 

others). 

Mention  should  be  made  of  the^ 
subcutaneous  incisions  which  are 
employed  for  such  cases  as  the  di- 
vision of  contracted  tendons,  club- 
foot, etc.  The  so-called  "  tenotomy 
knife  "  is  used  for  this  purpose  ;  it 
is  a  small,  sharp-pointed  knife  with 
a  curved  blade  and  a  stout  handle 
(Fig.  57).  With  this  knife  the  skin 
is  punctured,  and  the  tendon  is  di- 
vided beneath  the  skin  without  cut- 
ting through  the  latter. 

For  holding  and  retracting  the 
tissues  after  division  of  the  integu- 
ment we  use  particular  instruments, 
especially  the   surgical   thumb  for- 
^     ^,     ,,        ,       ,    ,  .  ceps,  clamps,  and  hooks.     Sursdcal 

Fig,  61.— Muzeux's  toothed  torcep.* :  a,  with-        ^        \      i-  . 

out;  6,  with  a  clasp  on  the  handles.  thumb  forccps  differ  from  the  ana- 


§24] 


THE   DIVISIOlSr  OF   THE   SOFT   PARTS. 


7a 


tomical  kind  in  having  two  to  four  small  teetli  at  the  end  of  the  blade, 
to  enable  them  to  get  a  better  hold  on  the  tissues.  Hooked  thumb 
forceps  (Fig.  58,  b\  fitted  with  rather  long,  curved  hooks,  are  excellent 
for  certain  purposes,  such  as  seizing  small  cutaneous  tumours.  The 
larger  hooked  thumb  forceps  of  this  kind  can  be  closed  and  locked 
by  a  spring  (Fig.  60).  There  are  numerous  other  kinds  of  forceps 
for  grasping  the  tissues,  sharp  and  blunt,  and  of  various  shapes  for  the 
particular  kind  of  operation  in  which  they  are  intended  to  be  used. 
Among  the  blunt-bladed  variety  are  the  sequestrum  or  dressing  for- 
ceps (Fig.  59),  straight  and  bent,  and  Luer's  forceps,  which  have  on 
the  handles  a  self -locking  ratchet  to  keep  them  closed.     Another  kind 


h  c  d 

Fig.  62. — Eetractors  (sharp  and  blunt). 


is  the  well-known  forceps  of  Muzeux,  which  are  straight  or  bent,  and 
are  provided  with  hooks  (Fig.  61,  «,  h).  These  hooked  forceps  have 
from  two  to  eight  or  more  curved,  sharp  hooks  on  the  end  of  the  blades. 

For  making  couuter  openings  quickly  and  without  loss  of  blood,  Wolfler 
uses  a  cutting  sequestrum  forceps,  which  is  made  with  one  blade  prolonged 
into  a  lance-shaped  point,  so  that  it  can  either  be  protruded  beyond  the  other 
blade  of  the  forceps  (unsheathed  perforating  forceps),  or  by  withdrawing 
the  sharpened  blade  the  latter  is  easily  covered  (producing  the  sheathed  per- 
forating forceps).  The  sheathed  forceps  is  suited  for  those  cases  in  which, 
to  make  a  counter  opening,  a  considerable  mass  of  soft  parts  must  be  trav- 
ersed, as  in  compound  fracture,  extensive  phlegmonous  processes,  for  mak- 
ing counter  openings  at  the  bottom  of  the  true  pelvis,  etc. 

After  making  the  skin  incision  the  margins  of  the  wound  are  held 
apart  by  blunt  or  sharp  hooks,  to  enable  the  operator  to  obtain  a  better 


THE   DIFFEREXT   WAYS  OF   DIVIDING  THE  TISSUES. 


view  of  the  deeper-lving  parts  or  to  divide  tlieni.  Retractors  (Figs. 
(\'2  and  03)  are  either  simple  Idunt  hooks,  like  an  aneurism  needle  used 
in  tving  a  vessel,  or  an  ordinary-  sharp  hook  with  one  or  more  tines, 
or  a  blunt  hook  bent  at  a  right  angle.  In  case  of  emergency  a  re- 
tractor can  be  made  out  of  pliable  wire  (Fig.  64).  Self-retaining  re- 
tractors are  also  in  use. 

The  scissors  commonly  used  are  straight  or  curved  on  the  Hat,  or 
they  have  an  angular  bend.     The  various  kinds  of  scissors  designed 

for  particular  operations 
are  described  in  Regional 
Surgery.  The  scissors  are 
held  for  operating  in  the 
way  we  have  learned  to 
handle  them  in  anatom- 
ical practice.  I  frecpent- 
ly  give  the  preference  to 
scissors,  especially  in  the 
removal   of    tumours,   as 

D\  w^  /^^k  ^^^^y  facilitate  rapidity  in 

-     ■  /t^^\.  if       11  operating. 


Fig.  63. — Large  blunt  retractors,  cliiefiy  for 
abdominal  operations. 


Fig.  64. — Improvised 
retractor  made  of 
pliable  wire. 


Puncture  of  the  soft  parts  can  be  done  with  a  pointed  knife,  or 
a  trocar  or  hollow  needle,  for  the  evacuation  of  fluid — e.  g.,  from  the 
pleural  or  peritoneal  cavities,  or  from  the  scrotum  ;  or  for  diagnostic 
purposes,  to  determine  the  nature  of  the  contents  of  a  cavity,  or  the 
nature  or  a  tunjour;  or,  finally,  to  introduce  fluid  medication  into  the 
tissues  or  general  system. 

A  trocar  (Fig.  65)  consists  of  two  parts,  a  stylet  or  trocar  with  a  handle, 
and  a  tube  or  cannula  enclosing  the  stylet.  The  cannula  is  provided  with  a 
metal  shield  at  its  posterior  extremity.  Trocars  are  straight  or  curved,  the 
latter,  for  instance,  being  used  for  puncture  of  the  bladder  above  the  sym- 
physis pubis  in  case  of  retention  of  urine.  The  calibre  of  the  trocar  varies 
with  the  uses  to  which  it  is  intended  to  be  ])ut,  the  smaller  sizes  having  the 
advantage  that  they  cause  only  a  small  puncture,  and  the  disadvantage  that 


§24.] 


THE   DIVISION  OF   THE  SOFT   PARTS. 


T5 


Fig. 


66. — Method  of  holding  the  trocar 
in  making  a  puncture. 


they  take  a  long  time  to  evacuate  the  fluid ;  and  if  the  cavity  contains  a 

thick  fluid,  perhaps  mixed  with  flakes  of  fibrin,  the  liquid  may  finally  cease 
flowing-  from  obstruction  in  the  cannula.  The  method  of  holding 
the  trocar  for  making  a  puncture  is  illustrated  in  Fig.  66.  After  it 
has  been  introduced  far  enough,  the  shield  of  the  cannula  is  grasped 
by  the  left  hand,  the  stylet  or  trocar  is  withdrawn,  and  the  fluid 
then  escapes  through  the  cannula,  which  is  left  in  place.  Befoi'e 
using,  the  trocar  and  cannula  must  always  be  boiled  for  five  to  ten 
minutes  in  a  one-per-cent.  soda  solution.  In  former  times,  before 
these  precautions  were  taken,  and 
when  neither  the  skin  area  in  ques- 
tion nor  the  instrument  was  disin- 
fected, this  trifling  operation  was 
sometimes  accompanied  by  infec- 
tion of  the  albuminous  contents  of 

Fig.  65.     the  cavity,  with  ensuing  septic  in- 

Trocar.     flammation.      To    prevent  the  en- 
trance of  air — for  instance  into  the 

pleural  cavity,  Fergusson,  Fraentzel,  and  others  have  fitted  the  trocar  with  a 

certain  contrivance   which  will  be  described  in  the  text-book  on  Regional 

Surgery  (Puncture  of  the  Pleura). 

For  diagnostic  purposes,  the  exploratory  puncture  is  made  with  a 
very  fine  trocar,  or,  better  still,  with  an  aspirating  needle  (Fig.  69)  hav- 
ing a  tight-fitting  piston  and  joints.  After  inserting  the  hollow  needle 
of  the  syringe,  the  graduated  jDiston-rod  is  slowly  withdrawn,  thus  caus- 
ing the  fluid  contents  of  a  cavity  to  flow  into  the  barrel  of  the  syringe. 

For  aspiration  of  the  contents  of  a  cavity,  Dieu- 
lafoy,  Potaiu,  and  others  have  made  a  suitable 
apparatus  and  have  introduced  it  into  general  use. 
Syringes  have  also  been  constructed  on  the  plan  of 
Weiss's  stomach  pump  for  siphoning  off  or  pump- 
ing out  fluid  from  some  part  of  the  body.  An 
aspirating  apparatus  similar  to  Potain's  (Fig.  68)  or 
Alexander's  (see  next  page)  can  be  easily  made  from 
a  bottle  with  a  rubber  cork  and  two  glass  tubes, 

Dieulafoy's  Aspirator  (Fig.  67)  consists  of  a  cylinder 
with  a  capacity  of  forty-five  to  fifty  grammes,  fitted 
with  a  graduated  piston-rod  which  is  notched  at  A,  and, 
after  being  withdrawn,  can  be  held  fast  at  B.  At  C  and 
D  are  two  stop-cocks,  which  can  be  opened  or  closed, 
and  the  hollow  needle  is  connected  with  the  syringe  by 
a  rubber  tube.  Before  puncturing  with  the  needle  it  is 
best  to  withdraw  the  piston  and  form  a  vacuum  in  the 
barrel  of  the  syringe,  so  that  during  the  operation  there  can  be  no  disturbing 
of  the  needle  with  tearing  of  the  tissues.  Both  stop-cocks  C  and  D  ax'e 
closed  ;  the  piston  is  withdrawn  and  retained  at  B  by  turning  it  slightly  from 


Fig.  67. — Dieulafoy's 
aspirator. 


76 


THE   DIFFERENT  WAYS  OF   DIVIDING  THE  TISSUES. 


Fig.  68. — Potain's  aspirator. 


left  to  right.  The  cavity  of  the  cylinder  is  now  relatively  a  vacuum.  The 
upper  end  of  the  rubber  tube  is  then  fitted  on  the  stop-cock  at  the  end  of  the 
cylinder,  while  the  hollow  needle  attached  to  the  other  end  of  the  tube  is 
plunged  into  the  cavity  in  the  body  which  it  is  desired  to  empty.  The  stop- 
cock C  is  opened  and  the  liquid  flows  into  the 
cylinder.  To  empty  the  cylinder  of  the  liquid, 
the  cock  C  is  closed  and  D  is  opened,  and  by 
pushing  down  the  piston  the  liquid  flows  out 
of  D.  If  necessary,  this  can  be  repeated  one 
or  more  times.  Aspiration  can  also  be  prac- 
tised by  thrusting  the  needle  into  the  tissues 
first,  and  then,  after  closing  the  cock  D,  open- 
ing C\  and  by  withdrawing  the  piston  the  fluid 
is  allowed  to  flow  into  the  syringe. 

Potain's  Aspirator  (Fig.  68)  consists  of  a 
graduated  glass  flask  F,  which  is  closed  by  a 
rubber  stopper,  and  has  a  capacity  of  five  hun- 
dred grammes.  The  rubber  stopper  is  pierced 
by  a  metal  tube  divided  into  two  compart- 
ments, one  communicating  with  A,  the  other 
with  B.  One  rubber  tube  E  goes  to  the  pump 
G ;  the  other,  which  is  fitted  with  a  glass  tube 
C  to  enable  the  liquid  to  be  seen  as  it  passes,  is  fastened  to  the  latex'al  por- 
tion of  the  cannula  of  a  trocar.  The  cannula  is  fitted  with  a  stop-cock  D. 
This  apparatus  is  used  in  the  following  way :  The  cock  B  is  closed,  A  is 
opened,  and  a  vacuum  is  made  in  the  flask  by  means  of  the  pump  G  ;  then  A 
is  closed,  and  the  puncture  is  made  with  the  trocar.  The  stylet  H  is  then 
pulled  out,  and  the  cannula  is  closed  by  the  cock  D,  while  B  is  opened,  thus 
allowing  the  liquid  to  flow  out  through  the  cannula,  glass  and  rubber  tubes 
into  the  glass  vessel.  During  the  aspiration  the  suction  can  be  increased  by 
opening  the  cock  A  and  working  the  pump  G.  Alexander's  apparatus  is 
similar  to  Potain's.  In  place  of  the  pump  G  there  is  a  pear-shaped  rubber 
bulb  which  acts  as  a  suction  or  pressure  pump,  depending  upon 
whether  it  is  attached  to  the  rubber  tube.  The  new  aspirator 
invented  by  Debove,  in  which  all  stop-cocks  are  done  away  with, 
is  a  most  excellent  instrument.  By  a  quarter  turn  of  the  handle 
the  lateral  openings  of  the  cannula  and  trocar  can  be  made  to 
correspond,  and  thus  allow  the  fluid  to  escape.  The  apparatus 
can  be  easily  cleaned  (Illustr.  Monatssch.  der  arzt.  Polytech., 
June,  1889 ;  this  also  contains  a  description  of  the  automatic 
aspirator  of  Ruault). 

Finally,  we  often  puncture  the  tissues  with  a  hypo- 
dermic needle  or  a  similar  instrument  to  introduce  mor- 
phine, cocaine,  ether,  camphor,  mercury,  etc.,  into  the 
neighbouring  tissues  or  the  general  system.  The  hypoder- 
mic syringe  usually  contains  one  gramme,  and  the  piston- 
rod  is  suitably  marked  ofE  to  permit  an  accurate  measurement  of  the 
amount  of  medicament  administered.     After  filling  the  barrel  of  the 


EiG.  69.  _ 
Hypodermic 


25.] 


BLOODLESS  DIVISION  OF   THE   TISSUES. 


Y7 


syringe  with  the  fluid  to  be  used,  the  hollow  needle,  having  been  care- 
fully disinfected,  is  put  in  place,  and  the  air  is  driven  out  of  the  syringe 
by  holding  the  point  upwards  and  gently  pushing  on  the  piston.  To 
make  the  injection,  a  fold  of  skin  is  pinched  up,  the  needle  is  plunged 
into  the  subcutaneous  tissue,  the  syringe  is  emptied,  the  fold  of  skin  is 
released,  the  needle  is  withdrawn,  the  tip  of  the  left  index  finger  is 
placed  upon  the  point  of  puncture,  and  the  injected  fluid  is  evenly 
distributed  by  gently  rubbing  the  area  with  the  index  and  middle 
fingers. 

For  making  parenchymatous  injections  (that  is,  injections  of  medi- 
cated fluids  into  organs — e.  g.,  muscles,  glands,  joints,  etc.)  it  is  cus- 
tomary to  introduce  the  fluid  at  more  than  one 
]3oint,  particularly  if  large  amounts  of  a  medica- 
ment are  to  be  administered. 

The  Care  of  a  Hypodermic  Needle.— To  keep  a 
hypodermic  needle  in  a  serviceable  state,  it  should 
be  washed  out  with  water  after  use,  and  the  traces 
of  fluid  should  be  blown  out  of  the  needle — or,  bet- 
ter, dried  out  by  heating-  the  needle  in  a  spirit  lamp. 
This  prevents  the  needle  from  rusting,  keeps  it  from 
becoming-  stopped  up,  and  makes  it  unnecessary  to 
introduce  a  silver  wire  for  rendering  tbe  needle  per- 
vious. To  prevent  the  piston  from  drying-  and  to 
keep  it  tight,  it  is  worth  while  to  introduce  a  drop 
of  oil  occasionally  between  the  leather  washers. 

The  small  punctured  wound  made  by  the 
trocar  or  hollow  needle  can  be  covered  with 
iodoform -collodion  (one  part  iodoform,  ten  parts 
collodion),  or  with  a  bismuth  and  bichloride-of- 
mercury  solution  ;  only  exceptionally  would  an 
antiseptic  dressing  be  necessary. 

Chronically  inflamed  tissues,  and  more  par- 
ticularly those  which  have  undergone  caseous 
degeneration,  are  removed  by  scooping  and 
scraping  them  out  with  sharp  spoons  (Fig.  70). 

The  operation  is  called  "  scraping  out  "  (sinuses,  fistulse,  etc.).  Sharp 
spoons  are  straight  or  slightly  bent,  and  of  diflierent  sizes.  The  open 
raspatory  (Fig.  70,  c),  unlike  the  sharp  spoon,  has  two  sharp  edges. 

§  25.  Bloodless  Division  of  the  Tissues  by  Tearing,  Twisting,  etc. — 
Under  this  heading  comes,  in  the  first  place,  the  division  of  the  tissues, 
especially  the  loose  connective  tissue,  by  means  of  the  tips  of  the 
fingers,  the  handle  of  the  scalpel  or  the  director,  thumb  forceps,  clamps, 
etc. ;  then  the  tearing  out,  or  twisting  off,  or  squeezing  off  of  small 


Fig.  70. — Volkniann  spoons, 
a  and  b  ;  c,  open  scraper. 


THE   DIFFERENT   WAYS   OF   DIVIDING   THE   TISSUES. 


tumours — for  instance,  from  tlie  larynx  or  the  nose — l)y  the  use  of  spe- 
cial forceps.  In  all  such  cases  the  bleeding  is  so  slight  that  the  opera- 
tion can  in  fact  be  called  more  or  less  bloodless.  All  large  wounds 
produced  bj  blunt  instruments  bleed  but  little,  because  the  vessels  are 
twisted  and  squeezed  together  in  the  process. 

The  Division  of  the  Tissues  by  the  Ligature,  or  Strangulation,  is  an  anti- 
quated method  of  operating  ;  it  is  too  slow,  it  is  painful,  and  not  infrequently 
gives  origin  to  inflammatory  and  even  dangerous  suppurative  processes. 
Tlie  technique  of  its  use  is  briefly  as  follows :  The  particular  part  in  ques- 
tion— for  example,  a  pedunculated  tumour,  a  ha?morrhoidal  protrusion,  etc. 
— is  tightly  encircled  about  its  base  by  a  strong  silk  ligature  or  elastic  band, 
less  frequently  by  a  strand  of  silver  wire,  and  thus  gradually  death  of  the 
part  takes  place.  The  elastic  ligature  is  best  secured  by  passing  its  ends, 
kept  at  a  proper  tension,  througb  a  lead  ring,  the  sides  of  which  are  then 
pinched  together  by  a  pair  of  nippers.  The  silver-wire 
ligature  is  applied,  and  then  retained  by  twisting  the 
ends  around  each  other. 

Ecrasement. — Ecrasement  lineaire,  as  it  is  called  by 
Chassaignac,  who  devised  and  intro- 
duced it,  is  also  a  form  of  division 
of  tissues  by  ligature.  The  tissues 
are  divided,  or  rather  compressed, 
and  thus  necrosis  takes  place  at  the 
line  of  pressure  (Fig.  71).  The  chain 
of  Chassaignac's  ecraseur  is  like  a 
chain-saw  without  teeth,  and  is  made 
to  encompass  the  portion  of  tissue  to 
be  removed,  or  is  passed  through  a 
fistulous  tract  by  a  probe,  or  is  car- 
ried through  the  parenchyma  of  an 
organ  by  a  needle,  and  so  around 
part  of  the  organ,  as  in  grasping  a 
portion  of  the  tongue.  In  the  two 
latter  instances  the  chain  of  the  ecra- 
seur is  first  applied  and  then  laid  in 
the  shank  of  the  instrument.  By 
means  of  the  thumb-screw  at  the 
handle  end  of  the  instrument  the 
chain  ligature  can  be  shortened — 
that  is,  the  portion  of  the  tissue  in  the 
gra.sp  of  the  chain  is  gradually  cut 
through  by  pressure  necrosis.  Simi- 
lar instruments  have  been  brought 
forward  by  Luer  and  Charriere.  The 
wire  ecraseur  of  Maisonneuve  is  fitted 
with  a  wire  instead  of  a  chain  ;  by  turning  the  thumb-screw  at  the  handle 
of  the  instrument,  the  loop  of  the  wire  ligature  is  made  smaller.  Chassaignac 
and  Maisonneuve  have  tried  in  vain  to  introduce  ecrasement  more  widely 


Fig.  71. — Chain  ecraseur 
(Chassaignac-Mathieu). 


Fig.  72. — Wire  ecra- 
seur CMaisonneuve). 


25.] 


BLOODLESS  DIVISION  OF   THE  TISSUES. 


Y9 


into  operative  surgery,  urging-  as  advantages  of  their  method  the  absence  of 
haemorrhage,  and  particularly  the  diminished  chances  of  the  absorption  of 
septic  matter,  as  the  lymphatics  and  connective-tissue  spaces  are  more  or  less 
closed  by  pressure.  But  these  statements  are  exaggerated,  since,  in  the  first 
place,  there  is  no  cei'tainty  that  the  ecraseur,  as  it  cuts  its  way  through,  will 
not  cause  haemorrhage,  especially  from  medium-sized  arteries.  Quite  re- 
cently Doyen  has  modified  ecrasement  by  his  "  angiotripsy."  This  consists 
in  crushing  or  dividing  tissues  in  different  operations,  such  as  those  on  the 
stomach,  intestine,  uterus,  etc.,  with  special  forceps.  Any  vessels  are,  if 
necessary,  ligated.  Tuffier  went  a  step  further.  He  closes  the  vessels  by 
compression  with  a  specially  constructed  forceps  without  ligating  the  vessel 
before  or  afterwards.  He  reported  twenty-three  cases  of  vaginal  hysterec- 
tomy which  he  performed  with  his  angiotribe  without  ligatures  and  artery 
clamps. 

French  gynaecologists  have  recently  recommended  the  use  of  long  clamps 
in  place  of  ligatures  in  performing  vaginal  hysterectomy.  The  clamps  re- 
main in  position  from  two  to  four  days.  If  they  are  removed  too  soon,  seri- 
ous secondary  haemorrhage  may  take  place.  This  method  is  to  be  recom- 
mended in  suitable  cases  on  account  of  its  simplicity. 

The  Cautery — the  Paquelin  Thermo-cautery. — The  division  of  the 
tissues  by  the  cauterj  (red-hot  iron)  is  a  very  ancient  method,  and  in 
the  middle  ages  was  used  especially  by  the  Arabian  physicians.     The 


Paquelin's  thermo-cautery. 


ordinary  cautery  is  made  of  different-shaped  iron  or  brass  rods  with  a 
wooden  handle,  and  was  formerly  heated  red-hot  among  glowing  coals  ; 
but  now  it  is  usually  heated  in  the  flame  of  a  Bunsen  burner  or  a 
spirit  lamp. 

The  old-fashioned  cautery  is  at  present  entirely  supplanted  by 
Paquelin's  thermo-cautery  (Fig.  TS).  Every  physician  should  possess 
one  of  these  instruments.     The  apparatus  works  on  the  principle  that 


80 


THE  DIFFERENT  WAYS  OF   DIVIDING  THE  TISSUES. 


platinum,  after  being  sufficiently  heated  in  the  flame  of  a  spirit  lamp, 
will  be  made  red-hot  by  the  ignition,  in  the  already  hot  platinum,  of  a 
mixture  of  aLr  and  vapour  of  petroleum  ether  (hydrocarbon  compounds). 
In  this  process  the  petroleum  ether  is  decomposed  into  water  and  car- 
bonic acid,  thus  giving  rise  to  so  nmch  heat  that  the  platinum  becomes 
red-hot.  Paqiielin's  apparatus  (Fig.  73)  consists  of  a  glass  bottle  half 
filled  with  petroleum  ether  {F).  I  use  a  mixture  of  two  parts  of  ben- 
zine and  one  part  of  petroleum.  The  impure  benzine  is  better  than 
that  which  is  chemically  pure.  By  squeezing  the  rubber  bag  B,  the 
vapour  of  petroleum  ether  is  driven  out  of  the  bottle 
through  the  rubber  tube  and  through  the  hollow 
interior  of  the  instrument  into  the  hollow  space 
inside  the  platinum  tip.  The  therrao-cautery  is 
managed  very  simply  :  The  point  of  the  instrument 
is  heated  in  the  flame  of  a  spirit  lamp  for  a  couple 
of  minutes,  or  long  enough  to  reach  a  red  heat,  and 
then,  by  squeezing  the  rubber  bag,  the  benzine- 
petroleum  vapour  is  driven  out  of  the  bottle  into 
the  platinum  of  the  instrument,  where  it  becomes 
ignited.  In  this  way  a  very  excellent  cautery  is 
prepared,  capable  of  very  powerful  action.  The 
most  useful  tips  are  those  with  bulbous  and  knife- 
shaped  extremities,  like  the  so-called  fistula  cautery- 
tip  illustrated  in  Fig.  73.  Platinum  scissors  the 
blades  of  which  can  be  made  red-hot  are  not  useful, 
and  can  always  be  dispensed  with.  The  Paquehn 
thermo-cautery  is  in  many  respects  better  than  the 
galvano-cautery,  which  Avill  next  be  described ;  but 
the  latter  has  the  great  advantage  that  it  can  be  in- 
troduced cold — for  example,  into  the  nasal,  oi'ai,  or 
pharyngeal  cavity — and  at  any  moment,  by  closing 
or  opening  the  circuit,  it  can  be  brought  to  a  red 
heat.  The  advantage  of  the  Paquelin  lies  in  its  sim- 
plicity and  cheapness.  Paquelin  has  recently  per- 
fected his  cautery  so  that  it  can  be  put  to  various  uses,  and  can  be 
employed  in  mineralogy,  chemistry,  bacteriology,  etc. 

As  a  substitute  for  the  Paquelin  cautery  Dechery  has  recommended  the 
aphyso-thermo-cautery  ("  ai^hyso-cautere '").  which  after  previous  warming 
with  ether  comes  to  a  red  heat  of  itself. 

Galvano-cautery. — The  galvano-cautery  was  brought  into  general 
use  by  Middeldorpf.  The  most  important  instrument  is  the  galvano- 
■cautery  made  of  a  platinum  wire  loop  (Fig.  74j,  which  is  tightened  by 


Tig.  74. — Galvano- 
caustic  loop  of 
platinum  wire. 


§25.] 


BLOODLESS  DIVISION  OF  THE  TISSUES. 


81 


turning  the  ivory  thumb-screw  C.    MA  A  the  instrument  is  connected 
^th  a  battery  by  two  conducting  wires,  and  by  closing  the  circuit  the 


wire  is  brought  to  a  red  heat.     By  pushing  the  key  B  forwards  or 
backwards,  the  current  is  made  and  broken.     Instead  of  the  expensive, 

frail,  and  so  easily  broken  platinum  wire, 
Voltolini  has  recommended  the  cheaper 
steel  wire  (piano  wire)  for  use  in  the  gal- 
vano-cautery,  and  this  answers  every  pur- 
pose perfectly. 

For  managing  the  galvano-cautery  loop 
with  one  hand,  a  special  handle  has  been 
devised ;  one  of  the  best  is  that  of  Bruns, 
which  has  been  recently  improved  by  Boker 
(Fig.  75).  There  are  three  rings  on  this 
handle,  for  the  thumb,  index,  and  middle 
fingers  respectively,  the  fourth  finger  being 
held  in  the  key  which  breaks  and  closes 
the  circuit.  The  ring  for  the  index  finger 
is  fastened  to  the  movable  cross- 
piece  to  which  the  wire  making 
the  loop  is  attached.  By  flexing 
the  index  fingei*,  the  correspond- 
ing ring,  and  with  it  the  cross-bar 
and  attached  wire  loop,  are  drawn 
towards  the  thumb,  thus  narrow- 
ing the  loop.  L  L'  represent  the 
two  wires  connecting  the  instru- 
ment with  the  battery. 

The   other   kinds  of  galvano- 
cauteries  are  variously  shaped  ;  be- 
sides the  pointed  and  straight  platinum  points,  or  those  which  are  more 
or  less  curved,  there  are  the  spatula-shaped,  knobbed,  conical,  or  spiral- 
7 


Fig.  76.  —  Various  galvano-cau- 
teries  for  the  ear,  nose,  throat, 
and  larynx. 


Fig.  77. 

Porcelain 

burner. 


82 


THE  DIFFERENT   WAYS  OF  DIVIDING   THE  TISSUES. 


shaped  cauteries.  By  pressing  the  button  B  on  the  liandle  (Fig.  70) 
the  circuit  is  closed.  At  A  A  are  attaclied  the  wires  connected  with 
the  galvanic  battery.  The  so-called  porcelain  cautery  (Fig.  77)  con- 
sists of  a  conical-shaped  piece  of  porcelain  with  a  spiral  of  platinum 
wire.  As  to  the  battery  for  working  the  galvano-cautery,  I  use  ex- 
clusively the  zinc-carbon-chromic-acid  battery  of  Voltolini  (Fig.  78). 
"We  shall  learn  in  Regional  Surgery  the  particular  cases  for  which  the 
galvano-cautery  is  suitable.  It  should  only  be  mentioned  in  passing 
that  even  major  operations — amputations,  for  example — have  been  j^er- 
formed  by  the  galvano-cautery  loop  under  exceptional  conditions ;  for 
instance,  to  prevent  loss  of  blood  when  a  very  high  grade  of  anaemia 
is  already  present.  Before  the  days  of  antisepsis,  Hagedorn,  by  means 
of  his  ecraseur  loop,  amputated  a  leg  and  a  thigh  without  primary  or 
secondary  haemorrhage,  and  without  applying  any  ligatures.  Bruns 
has  also  rejDeatedly  used  the  galvano-cautery  method  to  perform  ampu- 
tations. At  present  the  galvano-cautery  is  no  longer  used  for  amputa- 
tions, as  they  can  be  performed  by  the  knife  with  the  help  of  Esmarch's 
artificial  anaemia  without  loss  of  blood,  and  at  the  same  time  the  wound 

can  be  made  to  heal  by  primary  union  in  a 
very  short  time — a  thing  which  is  impossi- 
ble in  the  wound  made  by  the  galvano- 
cautery,  as  is  always  the  case  in  a  wound 
which  is  the  result  of  a  burn. 

Battery  of  Voltolini.— A^oltolini's  zinc-car- 
l:)on-chromic-acid    battery   (Fig.   78)    contains 
/        /'"^  ^!^^i^^^^  twenty-one  zinc-carbon   elements.     The  latter 

■''  °  were    originally    combined    in    the    so-called 

"  chain  " — all  the  cai'bon  elements  connected 
with  each  other  on  one  side  and  all  the  zinc  on 
the  other.  As  this  plan  gave  but  little  heating 
power,  Voltolini  improved  the  battery  by  add- 
ing a  contrivance  (A)  for  combining  at  will 
four  pairs  of  elements,  and  thus  succeeded  in 
heating  the  porcelain  cautery-tip  red-hot.  The 
fluid  used  in  the  battery  consists  of  one  part 
of  bichromate  of  i^otassium,  one  part  of  con- 
centrated (not  fuming)  sulphuric  acid,  and  ten 
parts  of  water. 
To  fill  the  battery,  the  cover  of  the  box  is  lifted  off  Avith  the  attached 
elements  by  seizing  the  handles  {B  B,  Fig.  78),  and  the  glass  vessel  contained 
in  the  box  is  half  filled  with  the  above-described  fluid.  The  elements  are 
then  replaced  in  the  box  and  the  connecting  wires  attached  to  the  battery 
and  the  galvano-cautery  instrument.  After  the  cover  (D)  of  the  battery  has 
been  put  back  in  its  horizontal  position,  the  fluid  contained  in  the  glass 
vessel  inside  the  box  surrounds  the  elements  and  the  battery  is  ready  for  use. 


Fig.  78. — Zinc-carbon-chromic-acid, 
batterv  for  the  galvano-cauterv. 


§25.]  BLOODLESS  DIVISION  OF  THE   TISSUES.  83 

If  the  cover  is  only  half  shut,  or  remains  open,  as  in  Fig.  78,  the  glass  vessel 
is  displaced  to  the  bottom  of  the  box,  the  fluid  does  not  touch  the  elements, 
and  the  battery  cannot  be  used.  The  cover  is  retained  at  any  desired  angle 
by  means  of  a  rod  fastened  to  it  on  the  outer  side  of  the  box.  After  using 
the  battery  the  elements  are  taken  out  of  the  box,  carefully  washed  off  with 
water,  and  dried.  The  zinc  plates  must  occasionally  receive  a  fresh  amalgam 
of  quicksilver ;  they  are  taken  out  of  the  battery,  dipped  in  dilute  sulphuric 
acid  (1  to  7  or  10),  and  then  treated  with  pure  mercury.  To  bring  the  mer- 
cury more  thoroughly  into  contact  with  the  zinc,  it  is  rubbed  into  the  plates 
of  the  latter  with  a  toothbrush  or  coarse  paper. 

Battery  of  Brims. — The  zinc-carbon-chromic-acid  battery  of  Bruns  is  an 
excellent  apparatus. 

Seller's  Battery.— Seller  has  also  introduced  a  new  form  of  battery  for  the 
galvano-cautery.  It  consists  of  zinc-carbon  elements  in  a  fluid  made  of  a 
mixture  of  sulphuric  acid  and  bichromate  of  potassium ;  the  elements  are 
immersed  in  the  fluid  by  turning  a  crank  connected  with  a  pedal.  The 
operator  keeps  his  foot  upon  this  during  the  operation,  and,  by  exerting 
more  or  less  pressure  w^ith  his  foot,  can  regulate  the  strength  of  the  current. 
To  protect  the  surrounding  parts  from  injury  while  the  cautery  is  heated, 
Seller  has  sheathed  the  part  of  his  cautery  instrument  not  intended  to  be- 
come red-hot,  and  the  connecting  wires  in  vulcanised  rubber.  .  * 

The  present  rapid  advance  in  electricity  enables  us  to  make  direct 
use  of  the  electric  current  without  using  a  battery  :  surgery  will  soon 
make  use  of  this  modern  acquisition  also,  and  thus  electrolysis  will  have 
a  new  field  opened  up  for  itself.  We  make  use  of  electric  light  in 
many  different  ways  in  the  performance  of  operations  and  for  diag- 
nostic purposes.  Special  illuminating  apparatus  have  been  devised 
for  different  parts  of  the  body,  such  as  the  bladder,  etc.  For  a  de- 
scription of  the  Roentgen  rays,  see  §  124. 

All  wound  surfaces  made  by  the  cautery  bleed  but  little  or  not  at 
all,  and  are  thus  in  a  manner  protected  from  infection,  as  the  micro- 
organisms present  at  the  time  are  destroyed,  and  the  resulting  dry 
eschar  is  an  unfavourable  soil  for  the  lodgment  of  new  ones.  More- 
over, wounds  made  by  burning  granulate  vigorously,  heal  quickly, 
and  form  a  cicatrix  which  has  a  marked  tendency  to  contract.  Sup- 
puration does  not  always  occur,  and  often  enough  wounds  of  this  kind 
heal  beneath  the  eschar  with  no  dressing  and  without  noticeable  sup- 
puration. 

Electro-puncture  (Electrolysis). — The  so-called  galvano- puncture  or 
electro -puncture  (electrolysis)  is  but  little  used  at  present.  It  consists 
in  inserting  platinum  or  gold  needles,  which  are  connected  with  the 
poles  of  a  strong  battery,  directly  into  the  tissue  but  not  too  far  apart. 
The  changes  thus  induced  in  the  tissues  are  limited  to  the  immediate 
neighbourhood  of  the  needles.     In  other  cases  only  a  single  platinum 


S4:  THE   DIFFERENT  WAYS  OF   DIVIDING  THE  TISSUES. 

needle  connected  with  tlie  anode  or  cathode  is  inserted  into  the  tissues 
in  question — for  instance,  into  a  tumour — and  a  metal  plate  connected 
with  the  other  pole  is  placed  upon  the  skin.  The  negative  pole  (the 
cathode)  appears  to  have  a  more  powerful  action  than  the  positive  (the 
anode).  Kecently  electrolysis  has  come  into  more  frequent  use  for 
operative  purposes,  especially  in  the  case  of  tumours  which  are  difficult 
of  access,  like  naso-pharyngeal  tumours  and  libromata  of  the  uterus, 
for  strictures  of  the  urethra,  etc.  In  gynaecology  the  electrical  treat- 
ment of  women's  diseases  inaugurated  by  Apostoli  has  occasionally 
produced  surprising  results.  I  agree  with  Kuttner,  that  under  certain 
conditions  electrolysis  offers  us  hopes  of  success,  by  being  applicable 
to  deeply  seated  regions,  when  other  means  fail  entirely.  Xewman 
has  obtained  excellent  results  in  stricture  of  the  urethra.  Generally 
speaking,  the  negative  pole  (cathode)  is  destructive  in  its  action,  while 
the  positive  pole  (anode)  acts  as  a  haemostatic. 

Electro-puncture  in  Aneurism.— I  have  used  electro-puncture  in  cases  of 
aortic  aneurism  with  very  good  results.  It  acts  by  exciting  coagulation  of 
blood  in  the  aneurismal  sac,  which  becomes  diminished  in  size,  and  its  walls 
are  distinctly  thickened.  I  use  Stohi-er's  zinc-carbon  battery,  and  regulate 
the  current  by  a  dynamometer  and  a  fluid  rheostat.  By  means  of  the  first 
the  strength  of  the  current  can  be  determined  each  time  it  is  used,  and  by 
means  of  the  rheostat,  made  of  a  mixture  of  concentrated  suliiburic  acid  and 
oxide  of  zinc,  the  process  is  made  as  painless  as  possible,  since  at  the  begin- 
ning one  can  allow  the  stream  to  increase  in  strength  very  gradually.  At 
the  close  of  the  sitting  the  current  is  made  to  gradually  decrease  in  strength 
by  means  of  the  rheostat.  A  sterilised  fine  steel  needle,  ten  centimetres  long, 
is  plunged  into  the  aneurism  Avitb  every  antiseptic  precaution,  the  needle 
being  connected  with  the  anode,  as  the  latter  is  preferable  for  causing  coagu- 
lation of  the  blood,  while  the  other  pole  (the  cathode)  is  attached  to  a  metal 
lilate  which  is  placed  on  the  skin  on  the  opposite  side  of  the  thorax.  The 
length  of  the  sitting  should  be  five  to  ten  minutes,  and  the  strength  of  the 
current  twenty  to  thirty  milliaraperes. 

The  Destruction  or  Division  of  Tissue  by  Chemicals.— Co  H.sf/cs.— There 
are  solid,  soft,  and  fluid  caustics  whicli  are  used  in  the  form  of  a  i^aste,  pow- 
der, or  a  fluid.  At  present  caustics  ai*e  used  much  less  often  than  formerly 
for  the  destruction  of  soft  parts.  Of  the  solid  caustics  the  most  important 
are  hydroxide  of  potassium  or  caustic  potash,  nitrate  of  silver,  and  sulphate 
of  copper  (bluestone). 

Caustic  Potash. — Caustic  potash  is  applied  in  the  form  of  a  stick  in  a 
holder,  thumb  forceps,  or  wrapped  in  a  piece  of  cotton  for  a  handle.  The 
most  useful  holder  is  an  instrument  made  like  a  pair  of  pincers,  having  hol- 
low jaws,  with  a  contrivance  for  closing  them  made  in  the  form  of  a  mov- 
able blunt  hook.  As  the  caustic  has  a  tendency  to  spread  and  "  run  "  while 
being  used,  it  is  wise  to  carefully  protect  the  surrounding'  parts.  An  old- 
fashioned  way  was  to  form  an  eschar  on  the  skin  by  applying  caustics 
between  two  pieces  of  sticking  plaster,  the  one  next  the  skin  having  a  hole 


§25.]  BLOODLESS  DIVISION   OF   THE  TISSUES.  85 

cut  in  it  to  permit  the  caustic  to  act  upon  the  skin.  This  dressing  was  ap- 
plied to  any  particular  portion  of  the  skin  with  compresses  and  bandages 
for  six  to  seven  hours,  until  the  eschar  formation  was  completed. 

Nitrate  of  Silver.— '^\l\Qr  nitrate  comes  in  the  form  of  a  cylindrical  pen- 
cil, which  is  generally  provided  with  a  handle,  and  is  applied  to  hasten  the 
skinning  over  of  a  granulating  surface.  The  sticks  of  silver  nitrate  which, 
like  our  ordinary  lead  pencils,  are  enclosed  in  a  wooden  sheath,  are  most 
excellent.  The  so-called  "  modified  stick  "  of  silver  nitrate  is  made  of  nitrate 
of  silver  and  saltpetre  (equal  parts,  or  one  part  of  the  former  to  two  of  the 
latter).  These  sticks  are  less  brittle  and  have  a  milder  action.  The  action  of 
bluestone  (sulphate  of  copper)  is  still  milder,  and  this  material  is  used  almost 
exclusively  in  diseases  of  the  eye. 

Other  Caustics.— Among  fluid  caustics  are  the  mineral  acids,  the  most 
useful  being  concentrated  sulphuric  acid  and  fuming  nitric  acid.  Besides 
these  there  should  be  mentioned  hydrochloric,  acetic,  monobrom-acetic,  and 
bichlor-acetic  acids  ;  also  concentrated  solutions  of  lactic  acid,  caustic  potash, 
bichloride  of  mercury,  chloride  of  zinc,  chromic  acid,  antimony,  etc.  The 
fluid  caustics  are  injected  into  the  tissues  by  a  hypodermic  syringe,  and  this 
can  occasionally  be  practised  in  inoperable  cases,  such  as  tumours.  Of  the 
milder  caustics,  the  best  known  are  the  so-called  "  Vienna  paste  "  and  the 
pastes  consisting  of  arsenic  and  of  chloride  of  zinc. 

Vienna  Paste.— To  make  Vienna  paste,  five  parts  of  caustic  potash  and 
six  parts  of  quicklime  are  made  into  a  thick  paste,  immediately  before  using, 
by  the  addition  of  the  necessary  amount  of  alcohol.  The  paste  is  then  spread 
about  five  millimetres  thick,  by  a  wooden  spatula,  over  the  area  selected  for 
cauterisation,  and  allowed  to  remain  from  four  to  fifteen  minutes,  or  until  the 
desired  effect  is  obtained.  After  six  minutes  at  the  latest  there  appears  at  the 
edge  of  the  paste  a  gray  line,  which  indicates  that  cauterisation  or  eschar  for- 
mation is  taking  place  in  the  area  covered  by  the  paste.  After  the  removal 
of  the  paste  the  skin  which  it  covered  should  be  washed  off  with  vinegar. 

Ai'sefiic  Paste. — Make  a  dough  of  one  part  of  arsenious  acid  and  fifteen 
parts  of  starch  and  water.  The  eschar  forms  after  a  few  days,  during  which 
there  is  severe  pain.  If  too  much  paste  is  applied  symptoms  of  poisoning 
are  very  apt  to  appear. 

Chloride-of-Zinc  Paste  (Canquoin's  Paste).— One  part  of  chloride  of 
zinc  and  two  to  four  parts  of  flour,  according  to  the  amount  of  cauterisa- 
tion desired,  are  mixed  with  just  enough  water  to  make  a  rather  thick,  stiff 
dough.  The  thicker  the  dough  is  spread  out  over  the  skin  the  more  intense 
its  action.  Before  applying  the  paste  the  epidermis  should  be  removed,  as 
it  resists  the  cauterising  power  of  the  chloi-ide  of  zinc.  The  action  of  this 
paste  is  very  painful. 

Rivalliffs  Caustic. — Rivallie  has  introduced  a  useful  caustic.  By  drop- 
ping concentrated  nitric  acid  upon  charj)ie  or  cotton-wool  in  an  earthen 
vessel  there  results  a  gelatinous  mass,  which  can  be  picked  up  with  forceps 
and  applied  to  the  skin,  and  after  a  quarter  to  half  an  hour  a  yellow  circum- 
scribed eschar  forms.  After  about  twenty-four  hours  the  eschar  can  be  for 
the  most  part  separated,  and  the  cauterisation  may  then  be  repeated.  Not 
the  smallest  amount  of  bleeding  results,  even  though  the  caustic  be  left  in 
place  for  twenty-four  hours,  and  the  pain  is  very  slight. 


86 


THE   DIFFERENT   WAYS   OF   DIVIDING  THE   TISSUES. 


1 


Caustic  Points. — In  conclusion,  mention  should  be  made  of  the  method 
of  cauterisation  used  by  Maisonneuve  {cauterisation  en  fleches).  It  is  a  very 
painful  and  slow  procedure,  which  at  present  i3  scarcely  ever  used.  By 
means  of  a  sharp-pointed  bistoury  the  superficial  portion  of  a  tumour  is 
incised  in  lines  radiating  to  its  base,  or  else  the  base  is  punctured  repeatedly 
all  around,  and  in  each  of  these  ])unctures  there  is  introduced  a  long,  pointed, 
solid  stick  of  some  caustic,  or  the  incisions  are  filled  with  pieces  of  cotton  or 
strips  of  linen  soaked  in  some  fluid  caustic. 

§  26.  The  Division  of  Bone. — "We  use  the  so-called  raspatory  and 
periosteal  elevator  before  dividing  a  bone,  in  order  to  raise  and  so  pre- 
serve the  periosteum — as,  for  example,  in  the  subperiosteal  resection  of 
the  bone  near  a  joint.     The  ends  of  raspatories — i.  e.,  their  blades — are 

sharpened  (Fig.  79),  and  either 
curved  (Fig.  T9,  a)  or  straight 
(Fig.  79,  />,  c).  Elevators  serve 
to  prv  off  the  periosteum  with- 
out cutting  it,  and  are  therefore 
blunt-edged,  and  either  straight 
or  slightly  curved  (Fig.  80,  a), 
or  they  are  sometimes  shaped 
like  a  goat's  foot  (Fig.  80,  h). 

To  remove  a  part  of  a  bone 
or  to  completely  divide  it,  we 
use  chiefly  the  chisel  or  cutting 
bone  forceps  and  the  saw. 

Chisels,  which  are  made  of 
the  best  steel, have  either  grooved 
(Fig.  81,  h,  d)  or  flat  blades  (Fig.  81,  a,  c,  e).  Instruments  with  a  circu- 
lar cutting  edge  (Lauenstein)  are  also  useful  in  some  cases.  They  vary 
much  in  strength,  breadth,  and  length,  and  have  their  edges  straight 
across  or  slanting.  It  is  better  to  have  the  handle  made  not  of  wood, 
but  of  metal,  in  order  that  the  sterilisation  of  the  chisel  by  boiling 
may  be  more  complete.  The  hammers  used  in  chiselling  (Fig.  82) 
are  made  of  wood  or  metal.  For  dividing  the  large  hollow  bones  I 
use  the  broadest  form  of  chisel,  as  is  recommended  by  Konig.  And 
for  these  large,  broad  chisels  I  prefer  wooden  handles,  which  can 
be  easily  replaced  if  they  become  damaged  by  boiling  in  a  one-per- 
cent, soda  solution.  They  are  not  to  be  applied  at  right  angles, 
but  obliquely  to  the  long  axis  of  the  bone.  In  cases  where  it  is 
necessary  to  chisel  at  some  depth  below  the  surface,  and  it  is  im- 
possible to  keep  perfect  control  of  the  action  of  the  chisel,  Roser 
recommends  that  the  chiselling  be  performed  with  three  hands :  i.  e., 
an  assistant  bolds  the  chisel  while  the  operator  does  the  hammering, 


Fig.  79. — Raspatories,    a  and  h 
are  Langenbeck's,  c  is  Ollier.s. 


Fig.  80.— Ele- 
vators. 


§26.] 


THE   m\^SIOX   OF    BONE. 


87 


and  with  the  index  finger  of  his  other  hand  controls  the  blade  of 
the  chiseL 

The  cutting  bone  forceps  (Fig.  83)  or  bone  shears  (Fig.  8i)  is  used 
to  remove  projecting   angles  or  portions  of   bone,  or  to  completely 


Fig.  81.— Chisels. 


Fi&.  82. — Hammers  for  the 
chisels. 


divide  a  flat  bone  like  a  rib,  the  lovrer  jaw,  etc.     The  rongeur  or  gouge 
forceps  of  Luer  (Fig.  83,  d)  can  also  be  used  for  holding  a  bone.     The 


led 
Fig.  83. — Bone  forceps,     a  and  5  are  Listen's,  c  is  Eoser's,  d  is  Luer"s. 

best  forceps  for  grasping  a  bone,  etc.,  is  that  of  Langenbeck  (Fig.  85). 
The  bones  of  children,  particularly  the  soft,  half -cartilaginous  epiph- 


88 


THE   DIFFERENT   WAYS   OF   DIVIDING   THE   TISSUES. 


yses  and  spongy  bones,  like  the  carpal  and  tarsal  bones,  can  often  be 
divided  with  a  knife.  The  short,  strong  resection  knife  is  the  best 
suited  for  this  purpose. 


Fig.  84. — a.  Bone-cutting  forceps;  6,  bone-cutting  forceps 
for  use  in  resection  of  ribs ;  c,  the  two  halves  of  b. 


Fig.  85.— Forceps  for  hold- 
ing a  bone  (Langenbeck). 


For  sawing  bone  we  use  bow  saws  (Fig.  86),  narrow-bladed  (Fig. 
87),  and  chain  saws  (Fig.  88).     The  broad,  flat  saws  have  now  passed 


Fig.  86.— «,  Bow  saw ;  J,  Butcher's  saw ;   c,  meta- 
carpal saw. 


Fig.  87. — Phalangeal  or  key-hole 
saws;  a,  6.  Adams's. 


entirely  out  of  use.     Butcher's  saw  (Fig.  86,  li)  is  a  very  good  one  ;  its 
blade  can  be  drawn  tight  or  relaxed  by  means  of  the  screw  in  the  top- 


§26.] 


THE  DIVISION  OF   BONE. 


89 


Chain  saw. 


Fig.  89.— Flexible  direc- 
tor for  the  chain  saw. 


most  crossbar,  the  latter  being  connected  by  a  liinge  joint  with  the 
two  bars  running  at  right  angles  from  its  extremities.  Thus  these  two 
bars,  by  means  of  the  hinge 
joint,  can  exert  traction  in  the 
line  of  the  long  axis  of  the  saw 
blade,  and  the  latter  can  make 
a  curved  cut  in  bone.  For  di- 
viding small  bones  like  the  pha- 
langes the  so-called  phalangeal 
(Fig.  86,  g)  or  narrow-bladed 
saw  is  used  (Fig.  87).  The 
latter  saw  can  be  introduced 
through  a  punctured  wound  in 
the  soft  parts.  For  many  oper- 
ations Adams's  narrow-bladed 
saw  is  one  of  the  best  (Fig.  87,  h).  Jeffray's  (1784)  chain  saw  (Fig. 
88)  consists  of  numerous  hnks  connected  by  hinges,  and  each  extremity 
of  the  chain  is  provided  with  a  hook  for  connecting  it  with  the  handles. 
The  chain  saw  is  carried  around  behind  the  bone 
either  by  the  hand,  or  a  ligature  threaded  on  a 
blunt  curved  needle,  or  a  curved  probe  with  an 
eye  at  the  end,  or  by  an  instrument  like  the  one 

illustrated  in  Fig.  89. 
The  guide  in  Fig.  89  is 
provided  with  an  eye  for 
the  thread,  by  means  of 
which  the  chain  saw  is 
brought  in  position  for 
use  —  for  example,  be- 
hind the  neck  of  the 
femur.  The  earlier  in- 
struments of  this  class 
were  made  of  steel  or 
iron ;  but  I  have  substi- 
tuted for  them  a  copper 
rod  which  can  be  bent 
and  which  has  a  steel 
handle,  and  thus  I  can 
give  it  any  bend  I  desire. 
The  chain  saw  should  be 
handled  gently,  and  with  moderate  traction  exerted  at  the  most  obtuse 
angle  possible.     If  too  much  force  is  used  the  chain  may  break,  and 


Fig.  90.- 


-Dental  engine  with  different  kinds  ot  drills  and 
saws  which  are  inserted  at  a. 


90 


THE   DIFFERENT  WAYS   OF   DIVIDING   THE   TISSUES. 


if  the  tension  upon  tlie  chain  is  uneven  it  may  become  jammed  in 
the  bone.  If  this  occurs  the  saw  should  be  pushed  back  a  Httle  with 
the  thumb  and  index  linger.  Gigli's  tine  Hexil^le  wire  saws  ai-e  very 
useful  and  cheap. 

Rotation  Saws. — OlUer,  acting  on  the  suggestion  of  the  circular  saw 
so  widely  used  in  the  arts,  has  invented  a  ''  rotation  saw "  which  is 
worked  by  a  crank,  and  by  means  of  which  pieces  of  bone  of  any  desired 
shape  and  size  can  be  cut  out.  The  dental  engine  (Fig.  90),  with  its 
diiferently  shaped  burr  drills,  is  used  a  good  deal  in  surgical  operations, 
such  as  trephining,  suturing  bone,  making  holes  in  bone,  etc.  A  drill 
with  a  handle  attached  is  to  be  preferred  to  the  machine  shown  in 
Pig.  90,  as  it  can  be  controlled  more  exactly.  In  place  of  the  dental 
engine,  which  is  worked   by  the  foot,   I  use  at   present  an  electi-o- 


FiG.  91. — Electromotor  with  circular  saw,  a. 


motor  which  is  set  in  motion  by  an  accumulator.  My  electromotor 
has  a  rheostat  and  a  movable  stand.  I  use  it  for  sawing,  suturing, 
and  making  holes  in  bone,  and  for  centrifugal  purposes.  As  the 
motor  only  requires  a  current  of  1.3  to  1.5  milliamperes,  the  accu- 
mulator ordinarily  used  for  an  illuminating  apparatus  can  be  employed 
for  this  motor.  Mention  should  finally  l)e  made  of  the  different 
forms  of  trephines  which  are  used  for  making  circular  openings  in 
the  skull. 

Among  other  instruments  used  in  bone  operations  are  the  sharp 
spoons  (see  page  Y7)  for  scraping  bone  which  has  become  inflamed  and 
broken  down ;  also  the  different  kinds  of  drills  for  making  holes  in 
bone — for  example,  to  insert  a  bone  suture  (see  Fig.  110).  The  bone 
files  for  smoothing  and  rounding  off  the  edges  of  a  bone — for  instance, 
after  it  has  been  sawed  across — are  no  longer  used,  but  their  place  has 
been  taken  by  the  simple  chisel  or  Liston's  bone  forceps. 


§36.]  THE   DIVISION   OF   BONE.  91 

Osteoclasis. — Either  the  hands  of  the  operator  or  special  instruments 
(osteoclasts)  are  nsed  to  fracture  a  bone  (osteoclasis)  when,  for  example, 
a  fracture  has  healed  in  a  faulty  position,  or  when  there  is  a  curvature 
of  bone  resulting  from  rhachitis.  CoUin,  Eobin,  Molliere,  Ferrari, 
Beelj,  and  Gratteau  have  each  devised  osteoclasts. 

In  spite  of  the  manifold  improvements  in  the  osteoclasts  the  instru- 
ments cannot  even  yet  be  rehed  upon  to  do  all  that  their  inventors 
claim.  Above  all,  it  is  very  difficult  to  fracture  a  bone  at  exactly  the 
desired  spot,  especially  if  it  is  in  the  neighbourhood  of  a  joint,  ^\ithout 
doing  some  injury  to  the  soft  parts. 


CHAPTEK  VI. 

rHE    METHODS    OF    ARRESTING    HEMORRHAGE. 

The  tying  of  vessels  (ligation). — Artery  clamps. — The  preparation  of  aseptic  ligature 
material  (catgut,  silk,  etc.). — The  substitutes  for  ligation. — Torsion. — Deep  suture. 
— Temporary  occlusion  of  the  lumen  of  the  vessel  by  artery  clamps. — Ligature 
of  a  part  of  a  vessel's  wall  and  suture  of  veins. — Pressure. — Packing. — Cauterisa- 
tion.— Other  methods  of  controlling  hjemorrhage. — Irrigation  with  hot  and  cold 
water. — The  suture  of  the  wound,  with  application  of  pressure  by  the  dressings 
as  a  means  of  stopping  ha?morrhage. — Old-fashioned  and  no-longer-used  methods 
of  stopping  haemorrhage  (acupressure,  acutorsion,  etc.). — Ligature  of  vessels  in 
their  continuitj'.  See  also  §§  18  and  19  (Prevention  of  Haemorrhage  in  Opera- 
tions, Esmarch's  Artificial  Ischa^mia). 

§  2Y.  The  Arrest  of  Haemorrhage  during  Operations. — We  distini^uish 
between  arterial,  venous,  and  capillary  or  parenchymatous  ha?morrhage. 
We  shall  here  discuss,  in  the  first  place,  the  arrest  of  haemorrhage  dur- 
ing an  operation. 

The  arrest  of  hemorrhage  from  a  wound  made  in  the  course  of  an 
operation  must  be  most  carefully  attended  to,  in  order  that  no  second- 
ary haemorrhage  may  interfere  ^vith  the  healing  of  the  wound  or  en- 
danger the  life  of  the  patient.  It  is,  in  general,  an  indispensable  requi- 
site for  obtaining  perfect  primary  union  that  all  haemorrhage  should 
be  checked  completely.  In  the  presence  of  dangerous  haemorrhage 
the  qualities  of  a  surgeon  are  revealed ;  coolness,  presence  of  mind, 
and  complete  familiarity  with  the  technique  of  operating  are  indis- 
pensable. We  have  already  learned,  in  the  consideration  of  Esmareh's 
bloodless  method,  in  what  way  serious  ha?morrhages  may  be  prevented 
in  any  operation. 

The  first  step  in  accurately  checking  haemorrhage  consists  in  tying 
off  (Hgation  of)  the  vessels,  both  veins  and  arteries,  which  have  been 
wounded  in  the  course  of  the  operation.  If,  for  example,  in  a  high 
amputation  of  the  thigh,  or  disarticulation  of  the  femur,  the  femoral 
vein  is  not  ligated,  it  is  perfectly  possible  for  dangerous  recurrent  or 
secondary  haemorrhages  to  take  place ;  and  as  a  matter  of  fact  this  has 
been  observed. 
93 


27.]      THE  ARREST   OF   HEMORRHAGE  DURING  OPERATION'S. 


93 


Attempts  to  diminish  or  prevent  haemorrhage  during  an  operation  are  as 
old  as  surgery  itself.  We  recall  with  a  shudder  the  times  when  amputation 
of  a  ]imb  was  performed  with  a  red-hot  knife,  or  when  the  amputation  stump 
was  plunged  into  melted  pitch  to  check  the  bleeding.  The  skilful  surgeons 
of  the  time  of  the  Roman  Empire  undei'stood  the  treatment  of  htemorrhao-e 
better  than  the  physicians  of  the  middle  ages,  were  familiar  with  the  lio-a- 
ture,  and  even  used  artery  clamijs.  All  this  was  entirely  forgotten  durino- 
the  middle  ages,  and  Ambrose  Pare  reintroduced  the  ligation  of  vessels  in 
the  sixteenth  century. 

We  tie  off  or  Jigate  the  vessels  in  the  wound  bj  seizing  their  open 
ends  with  so-called  artery  clamps  or  haemostatic  forceps,  which  are 
closed  and  locked  by  a  suitable  contrivance  (Fig.  92).     The  Fricke- 


Fi&.  92. — Hoemostatic  forceps  or  clamps. 


Amussat  clamp  (Fig.  92,  «,  5),  which  is  fastened  by  means  of  a  small 
sliding  piece  the  end  of  which  fits  into  a  ring  in  the  other  jaw  of  the 
forceps,  is  no  longer  used.  I  make  use  entirely  of  the  clamp  shown 
in  Fig.  92,  c,  which  differs  from  the  similar  instrument  of  Pean  and 
Koeberle  in  having  teeth  at  the  tip,  and  hence  takes  a  firm  grasp  of  the 
tissues. 

By  means  of  the  hsemostatic  forceps  or  clamps  the  isolated  end  of 
the  vessel  is  seized,  and,  if  necessary,  the  surrounding  tissues  are 
stripped  back  and  the  vessel  is  carefully  encircled  with  catgut  or  silk, 
which  is  then  tied  beyond  the  clamp.  In  the  case  of  large  arteries  the 
ligature  should  be  tied  in  a  surgeon's  knot ;  but  small  vessels  only 
require  the  ordinary  square  knot.  The  ends  of  the  ligature  are  cut 
short  after  the  clamp  has  been  first  removed  to  see  whether  the 
knot  holds  securely,  and  whether  there  is  any  danger  of  its  slipping. 


94 


THE   METHODS  OF   ARRESTING   HEMORRHAGE. 


The  surgeon's  knot  is  made  by  twisting  one  end  of  the  ligature  around 
the  other — not  once,  as  in  tpng  the  ordinary  knot,  bnt  twice.  The 
appHcation  of  hgatnres  en  masse,  as  they  are  called,  about  the  vessel 
and  the  snrrounding  tissue  should  be  avoided  as  much  as  possible. 
Instead  of  hteniostatic  forceps  or  clamps,  sharp-pointed  ho(As  are 
sometimes  nsed  to  draw  out  the  end  of  the  vessel.  If  for  any  reason 
it  is  imj^ossible  to  tie  a  bleeding  vessel,  one  of  the  other  methods  of 
stopping  haemorrhage  described  on  page  97  may  be  employed. 

Ligature  Materials. — Ligatures  are  made  of  catgut,  which  is  pre- 
pared from  the  intestine  of  the  cat  or  sheep,  and  of  silk.     Catgut  is 

absorbed  and  disappears 
completely,  while  silk,  on 
the  contrary,  remains  in 
the  tissues.  In  the  liga- 
tion of  large  arteries  and 
veins  I  prefer  silk  to  cat- 
gut, as  the  latter  may  be- 
come absorbed  before  the 
vessel  has  become  defi- 
nitely occluded,  and  in 
this  way  serious  second- 
ary haemorrhage  may  re- 
sult. Furthermore,  silk 
can  be  sterilised  simply 
and  completely  by  boiling,  while  the  sterilisation  of  catgut  is  still  uncer- 
tain in  spite  of  the  recent  improvements  in  the  methods.  For  this 
reason  I  prefer  silk.  The  latter  has  another  advantage  in  that  finer 
ligatures  can  be  used  than  in  the  case  of  catgut 
kept  in  glass  receptacles  similar  to  those  shown  in  Fig.  93 

Preparation  of  Aseptic  Catgut.— There  are  many  methods  for  killing  the 
germs  in  raw  catgut,  but  none  is  so  simple  and  sure  as  the  preparation  of  silk 
— viz.,  by  simply  boiling  it  in  water.  The  surgeon  who  makes  use  of  catgut 
must  see  that  its  sterilisation  is  carried  out  with  the  greatest  care,  and  must 
have  it  frequently  tested  bacteriological ly.  The  aseptic  methods  of  sterili- 
sation are  to  be  preferred  to  the  antiseptic,  because  the  aseptic  ligatures  do 
not  irritate  the  tissues.  Of  the  different  methods  of  sterilisation  about  to  be 
described,  I  prefer  Kronig's  cumol  method  and  my  formalin  method.  Even 
when  catgut  is  germ  free  it  may  give  rise  to  suppuration  of  a  benign  charac- 
ter, due  to  chemical  products  of  decomposition  in  the  catgut.  This  probably 
results  from  preparing  the  catgut  from  intestine  that  is  not  perfectly  fresh. 
It  is  hence  very  important  to  obtain  a  reliable  raw  catgut.  The  existence  of 
such  numerous  methods  of  sterilisation  shows  how  hard  it  is  to  get  a  really 
sterile  catgut.  It  is  very  important  to  make  from  time  to  time  bacteriological 
examinations  of  the  fluid  in  which  the  catgut  is  kept,  and  of  the  catgut  itself. 


Fig.  93. — Vessels  for  storing  sterilised  catgut  and  silk :  1, 
Glass  case  with  glass  spools  for  hospital  practice ;  2 
and  3,  glass  bottles  with  glass  rollers  and  India-rubber 
stoppers  for  private  practice  (see  also  Fig.  18). 


Silk  and  catgut  are 


-.]      THE  ARREST   OF   HEMORRHAGE  DURIXG   OPERATIONS. 


95 


SterUisation  by  Dry  Heat.— The  raw  catgut  must  first  be  soaked  for 
twenty-four  to  forty-eight  hours  in  absolute  alcohol  to  remove  all  water. 
Then  the  catgut  is  put  in  glass  tubes,  or  between  layers  of  blotting  paper,  or 
in  sealed  envelopes,  placed  in  the  dry  steriliser,  and  the  latter  heated  very 
slowly  (in  three  hours)  to  a  temperature  of  130°  to  150°  C.  The  catgut  is 
then  treated  for  three  hours  more  to  a  temperature  of  130°,  and  finally  the 
steriliser  is  cooled  off  slowly.  After  this  it  is  placed  for  six  to  eight  days  in 
oil  of  juniper  which  has  also  been  sterilised  by  heat,  and  then  it  is  stored  for 
use  in  a  one-per-cent.  alcoholic  solution  of  bichloride  of  mercury,  or  in  a  ten- 
per-cent.  solution  of  carbolic  acid  in  glycerine,  or  in  a  l-to-500  aqueous  solu- 
tion of  bichloride  of  mercury.  Brunner  places  the  catgut  in  xylol  in  a  closed 
vessel,  and  subjects  this  to  the  action  of  steam  at  a  temperature  of  100°  C. 
(212°  F.)  for  three  hours.  The  catgut  is  then  washed  in  alcohol  and  stored 
in  an  alcoholic  solution  of  bichloride  of  mercury. 

Krbnig's  Climol  Method.— Kronig  boils  the  catgut  in  cumol,  a  hydrocar- 
bon compound  of  which  the  boiling  point  lies  between  168°  and  178°.  He  has 
used  this  method  in  the  following  way  in  his  gynaecological  clinic  at  Leip- 
sic,  and  has  found  it  very  efiicient :  1.  The  catgut  is  wound  into  rings,  which 
are  made  to  keep  their  form  by  tying  three  or  fom-  pieces  of  string  loosely 
about  each.  2.  The  catgut  rings  are  heated  slowly  to  a  temperature  of  70°  C, 
and  this  temperature  is  maintained  for  two  hours.  3.  The  rings  are  placed 
in  cumol,  and  heated  in  this  fluid  upon  a  sand  bath  to  a  temperatu.re  of  155° 
to  165°  for  an  hour.  4.  They  are  then  placed  in  petroleum  benzine  for  three 
hours  in  order  to  remove  the  cumol  from  the  catgut,  and  are  kept  in  a  steri- 
lised glass  vessel. 

Chromicised  catgut,  which  is  more  slowly  absorbed,  is  prepared  from 
commercial  raw  catgut  by  subjecting  it  to  a  dry  heat  of  130°  C.  (266°  F.j,  and 
keeping  it  for  forty-eight  hours  in  a  ten-per-cent.  solution  of  carbolic  acid  in 
glycerine,  and  theii  for  five  hours  in  a  one-half-per-cent.  solution  of  chromic 
acid.  It  is  stored  in  a  five-  to  ten-per-cent.  solution  of  carbolic  acid  in  gly- 
cerine, or  in  a  one-per-cent.  alcoholic  solution  of  bichloride  of  mercury,  and 
immediately  before  use  it  is  placed  in  a  three-per-cent.  aqueous  solution  of 
carbolic  acid  or  bichloride  of  mercury.  Macewen  keeps  the  raw  catgut  for 
two  months  in  a  mixture  of  twenty  parts  of  glycerine  and  one  part  of  a  twen- 
ty-per-cent.  aqueous  solution  of  chromic  acid.  He  then  washes  it  and  stores 
it  in  a  twenty-per-cent.  solution  of  carbolic  acid  in  glycerine. 

The  Schiminelbusch  Method  (Bergmann's  Clinic). — The  glass  vessels  that 
are  to  hold  the  catgiit  and  the  glass  spools  are  sterilised  by  steam  for  three 
quarters  of  an  hour.  The  raw  catgut,  which  contains  fat,  is  rolled  on  spools 
and  soaked  for  twenty-four  hours  in  ether,  which  is  then  poured  ofi"  and 
replaced  by  an  alcoholic  solution  of  bichloride  of  mercury  (one  part  bichlo- 
ride, eighty  parts  absolute  alcohol,  and  twenty  parts  distilled  water),  which  is 
removed  at  the  end  of  twenty-four  hours.  According  to  whether  one  desires 
stiff  or  pliable  catgut,  the  latter  is  stored  in  absolute  alcohol  or  in  a  twenty- 
per-cent.  mixture  of  glycerine  and  alcohol,  or  in  the  alcoholic  solution  of 
bichloride  \ist  described. 

Braatz's  Method.— The  raw  catgut  is  soaked  in  ether  or  chloroform 
for  one  or  two  days  to  free  it  from  fat ;  it  is  then  placed  for  twenty-four 
hours  in  an  aqueous  solution  of  bichloride  of  mercury  (1  to  1,000),  or  else 


96  THE  METHODS  OF  ARRESTING  HAEMORRHAGE. 

sterilised  by  the  dry  heat  method  (see  page  95),  and  then  stored  in  absolute 
alcohol. 

Brunner's  Method. — According  to  the  investigation  of  Brunner,  the  cat- 
gut sterilised  by  treatment  with  bichloride  of  mercuiy  or  by  dry  heat  is  per- 
fectly stei'ile,  while  the  catgut  treated  with  carbolic  acid,  chromic  acid,  and 
oil  of  juniper  often  contains  fungi  and  bacteria.  He  recommends  the  fol- 
lowing method  :  Tlie  raw  catgut  is  first  scrubbed  with  green  soap,  and  then, 
either  immediately  or  after  soaking  for  half  an  hour  in  ether,  it  is  transferred 
to  an  aqueous  solution  of  bichloride  (1  to  1,000),  where  it  is  left  for  twelve 
hours.  It  is  then  stored  in  bichloride  of  mercury,  one  part ;  absolute  alcohol, 
nine  hundred  parts  ;  glycerine,  one  hundred  parts. 

Repin's  Method. — The  fat  is  first  removed  in  ether  or  carbon  di.sulphide. 
It  is  then  dried  in  an  oven  in  which  the  tempei'ature  is  gradually  raised  to 
110°  C.  The  next  step  is  to  place  it  immediately,  before  it  takes  up  water,  in 
a  tightly  closed  vessel  containing  absolute  alcohol,  and  heat  it  in  an  auto- 
tlierni  at  a  temperature  of  120°  C.  for  one  hour. 

Barthe's  method  is  similar  to  the  last.  In  order  to  obtain  a  less  brittle 
catgut  he  subjects  the  same,  after  removal  of  the  fat,  to  a  hot  current  of  air 
(80°  to  95°  C.)  in  a  special  vessel.  He  then  places  the  catgut  spools  in  small 
tubes  closed  with  cotton,  and  subjects  them  to  a  vapour  of  alcohol,  free  from 
water,  at  a  temperature  of  120°  C,  and  imder  a  pressure  of  four  atmospheres. 

Method  of  Halban,  Hlavacek,  and  Hofmeister.— One  layer  of  raw  catgut 
is  wound  on  rods  of  glass  or  nickeled  iron,  and  hardened  in  two-  to  four-per- 
cent, formalin  for  twelve  to  forty-eight  hours,  or  in  a  five-  to  ten-per-cent. 
solution  for  twelve  hours.  The  excess  of  formalin  is  then  removed  by  wash- 
ing it  off  in  running  water  for  twelve  hours  (Hofmeister).  The  catgut  is 
next  boiled  in  water  for  fifteen  to  twenty  minutes,  and  finally  hardened  and 
kept  in  absolute  alcohol,  with  the  addition  of  five  per  cent,  glycerine  and 
four  per  cent,  carbolic  acid  or  one  per  cent,  bichloride,  depending  upon 
whether  metal  or  glass  rods  have  been  used. 

Author's  FormaUn  Method. — One  layer  of  raw  catgut  is  I'olled  on  glass 
spools  and  placed  for  twelve  to  fortj'-eight  hours  in  four-per-cent.  formalin. 
The  spools  are  then  washed  off  with  running  water  for  twelve  to  twenty-four 
hours.  The  catgut  is  next  boiled  in  water  for  fifteen  to  twenty  minutes  and 
then  placed  in  absolute  alcohol  for  six  hours.     It  is  kept  in  oil  of  juniper. 

Saul's  Method. — The  raw  catgut,  suitably  wound,  is  placed  in  a  specially 
constructed  boiling  apparatus  containing  eight  hundred  and  fifty  parts  abso- 
lute alcohol,  fifty  parts  carbolic  acid,  and  one  hundred  parts  distilled  water. 
The  apparatus  is  heated  to  75°  C.  and  then  the  size  of  the  fianie  reduced  so 
that  the  temperature  rises  gradually  to  the  boiling  point  (78  to  80°  C).  which 
is  allowed  to  act  for  fifteen  minutes.  The  time  consumed  in  sterilisation  is 
forty-five  minutes. 

Harrington's  Method.— Harrington  sterilises  catgut  by  means  of  formalin 
vapour.  He  employs  the  dry  vapour,  which  does  not  weaken  the  catgut, 
whereas  the  moist  vapour  does. 

Jacobi  and  Eosenbach  recommend  the  impregnation  of  catgut  with 
iodoform  by  placing  it  for  six  to  twelve  hours  in  a  mixture  containing  iodo- 
form, five  parts ;  ether,  twenty  parts  ;  absolute  alcohol,  fifty  parts ;  and  gly- 
cerine, twenty  parts.     It  is  kept  either  in  the  dry  state  or  in  a  sterile  fluid 


§28.]  SUBSTITUTES   FOR  THE   LIGATION  OF  VESSELS.  97 

which  neither  alters  the  catgut  nor  removes  the  iodoform — for  example, 
g-lycerine,  iodoform,  oil,  etc. 

Preparation  of  Carbolised  and  Bicliloride  Silk.— The  carbolised  and  bi- 
chloride silk  is  prepared  by  winding  the  silk  on  hollow  glass  spools  and  then 
boiling  it  for  half  an  hour  in  a  five-per-cent.  aqueous  solution  of  carbolic 
acid,  or  a  l-to-500  solution  of  bichloride  of  mercury.  After  this  it  is  stored 
in  a  five-per-cent.  aqueous  solution  of  carbolic,  or  a  l-to-2,000  solution  of  bi- 
chloride of  mercury,  or  in  absolute  alcohol.  An  aseptic  silk  ligature  remains 
in  a  wound  as  a  foreign  body,  but  without  causing  any  reaction. 

Ligatures  of  Other  Materials. — Besides  catgut  and  silk,  ligatures  are  made 
of  chamois  leather  or  parchment,  from  the  aorta  of  the  ox,  from  horse-hair> 
and  from  the  tendons  of  mammals  like  the  kangaroo,  whale,  reindeer,  etc. 

§  28.  Substitutes  for  the  Ligation  of  Vessels.  —  Torsion  of  the  End  of 
the  Artery  {Amussat),  and  Deej)  Suturing. — Torsion  of  the  cut  end 
of  a  vessel  is  performed  by  seizing  the  end  in  a  lisemostatic  clamp  and 
twisting  it  several  times  on  its  long  axis.  The  lumen  of  the  vessel  is 
thus  closed  bj  rolling  up  and  tearing  the  walls  of  the  vessel,  especially 
the  middle  and  inner  coats.  Torsion  produces  more  accurate  closure 
of  the  lumen  of  the  vessel  if  the  latter  is  grasped  by  two  clamps — one 
at  the  end  of  the  vessel  and  held  in  its  long  axis,  the  other  clamp  be- 
hind the  first  and  at  right  angles  to  the  vessel.  The  clamp  on  the  end 
is  then  twisted  three  or  four  times  about 
the  long  axis  of  the  vessel.  Arteries  as 
large  as  the  axillary  and  femoral  can  be  so 
firmly  closed  by  torsion  that  no  bleeding 
will  occur.  But  if  branches  are  given  off 
close  above  the  bleeding  end  of  the  artery, 
the  latter  will  not  be  sufficiently  movable 
to  make  torsion  safe.  Murdoch  has  used 
torsion  successfully  in  a  large  number  of 
amputations -viz.,  torsion  of  the  femoral,  ^''^-  '^^n  iJe"  ylltSlfrir' ''  °^ 
160  times ;   the  popliteal,    24   times ;   the 

axillary,  24  times ;  the  anterior  and  posterior  tibial,  each  405  times ; 
the  brachial,  115  times  ;  the  radial  and  ulnar,  each  59  times.  Stilling 
recommends  drawing  the  end  of  the  artery  through  a  puncture  made 
in  the  artery  wall  (Fig.  94).  In  this  connection  mention  should  again 
be  made  of  Doyen's  and  Tuffier's  method  of  hfemostasis  called  "  angio- 
tripsy,"  consisting  in  compressing  the  vessels  by  special  forceps  (angio- 
tribe),  without  subsequent  ligation  (see  also  page  79). 

Deep  Suture  around  a  Vessel  ("  Umstechung "). — A  suture  passed 
through  the  tissues  around  a  vessel  is  similar  to  a  ligature  en  masse, 
because  the  surrounding  tissues,  as  well  as  the  vessel  itself,  are  included 
in  the  ligature  (Fig.  95).    A  sharply  curved  needle,  carrying  a  ligature, 


98  THE  METHODS  OF  ARRESTING  HAEMORRHAGE. 

is  passed  through  the  tissues  so  that  the  points  where  it  enters  and 
emero;es  he  close  together.  This  method  is  appUcable  for  those  cases 
in  which  the  bleeding  end  of  the  vessel  lies,  for  instance,  in  stilf,  un- 
vieldiug  tissues,  or,  for  one  reason  or  another,  cannot  be  sufficiently 
isolated  for  the  application  of  a  separate  ligature. 

Hsemostasis  by  passing  a  Suture  through  the  Skin  and  around  a  Vessel— 

Middeldorpfs  nietliod  of  passing  a  suture  through  the  skiu  and  around  a 
vessel  is  at  best  only  a  temporary  expedient.  For  example,  in  bleeding 
from  tlie  temporal  artery,  a  curved  needle  carrying  a  ligature  can  be  passed 
through  the  skin,  under  the  vessel  and  then  knotted  upon  the  skin.  A  simi- 
lar plan  is  sometimes  adopted  to  render  operations  on  the  tongue  bloodless. 
At  the  end  of  the  operation,  when  tlie  wound  in  the  tongue  has  been  closed 
by  sutures,  this  ligature  en  masse  is  removed. 

Temporary  Occlusion  of  the  Vessels  by  Clamps. — For  cases  in  which  the 
application  of  a  ligature  is  difficult  or  impossible,  it  may  be  expedient  to 

occlude  the  lumen  of  a  vessel  by  a  haemostatic 
clamp,  which  is  left  in  place  for  some  time. 
Kceberle  and  Pean  have  found  the  lumen  of 
vessels  perfectly  closed  after  the  expiration  of 
twenty-four  hours  with  this  method  of  hsemo- 
stasis. 

Simple  punctures  or  slits  in  the  wall  of  a 
large  vein  have  been  closed  by  the  application 
of  a  ligature  to  the  side  of  the  vessel.  The  in- 
jured portion  of  the  vein  is  seized  by  a  clamp, 
and,  while  slight  traction  is  made  upon  it,  a 
ligature  is  tied  around  the  puncture  beyond 
Fig.  95.— Hsetnostatic  suture.  the  jaws  of  the  damp,   and  thus  the   whole 

lumen  of  the  vessel  is  not  occluded.  This  lat- 
eral ligature  is  but  little  used,  as  it  easily  slips.  If  a  lai'ge  vein,  like  the 
common  femoral,  has  been  punctured,  and  there  is  fear  of  gangrene  of  the 
lower  extremity  if  the  whole  vein  is  tied  off,  it  is  best  to  close  the  puncture 
temporarily  with  an  artery  clamp  or  by  Schede's  method  of  suturing  with 
fine  catgut.  This  suture  of  veins  by  means  of  the  finest  needles  and  catgut 
has  been  performed  a  great  many  times  and  with  excellent  results.  Among 
the  veins  on  which  it  has  been  done  are  the  inferior  vena  cava,  the  axillary, 
and  the  jugular. 

Large  arteries  have  also  been  successfully  sutured.  Manteuffel.  for  exam- 
ple, sutured  the  common  femoral,  Isran  the  common  iliac  (five  interrupted 
silk  sutures),  and  Heidenheim  the  axillary  (continuous  catgut  sutures).  In 
all  three  cases  the  sutures  held  perfectly,  and  no  secondary  haemorrhage  or 
circulatory  disturbances  followed. 

Experimental  Investigations  on  the  Suture  of  Arteries  and  Veins.— The 
animal  experiments  made  by  Horoch.  Jassinowsky,  IMurphy.  and  others  in 
regard  to  the  suture  of  arteries  and  veins  have  given  favourable  results.  Su- 
ture of  the  wound  in  an  artery  resulted  in  a  sure  primary  union,  and  there 
was  no  haemorrhage  after  the  operation.  Some  of  the  experimenters  had  no 
cases  of  secondary  haemorrhage,  complete  thrombosis,  or  aneurism  forma- 


§29.] 


OTHER  METHODS  OF  H^MOSTASIS. 


99 


tion,  and  the  lumen  became  completely  restored  at  the  point  of  suture. 
Horoch,  however,  found  that  a  gi^adual  closure  of  the  artery  took  place 
at  the  point  of  suture — not  a  sudden  one,  as  in  the  application  of  a  liga- 
ture. If  a  vein  is  sutured,  the  lumen  persists  to  a  greater  or  less  degree,  and 
consequently  Horoch  prefers  suture  to  the  application  of  a  lateral  ligature,  as 
the  experiments  of  Blasius  show  that  lateral  ligation  of  a  vein  regularly  causes 
occlusion  of  the  latter's  lumen  by  a  thrombus.  Suturing  of  the  vessel's  wall 
is  particularly  applicable  in  longitudinal,  oblique,  and  "flap"  wounds,  pro- 
vided that  not  more  than  half  the  circumference  of  the  large  vessel  is  in- 
volved in  the  wound.  The  most  rigorous  asepsis  is  absolutely  essential  for 
success  in  suturing  a  portion  of  the  wall  of  an  artery,  for  which  the  finest 
silk  is  used  in  the  form  of  a  continuous  suture  with  interrupted  sutures 
through  the  adventitia  and  media.     In  the  case  of  veins  catgut  can  be  used. 

In  case  more  than  half  of  the  circumference  of  the  vessel  has  been  divided. 
Murphy  employs  invagination  of  the  two  ends  in  place  of  sutures.  He  used 
this  method  successfully  in  the  case  of  the  femoral  artery  in  the  human  sub- 
ject. The  method  is  as  follows  :  After  complete  division  of  the  partially 
divided  vessel  three  sutures  are  inserted  through  the  adventitia  and  media  of 
the  proximal  end,  and  the  ends  of  the  sutures  are  carried  from  within  out- 
ward through  the  distal  end.  The  proximal  end  is  then  drawn  into  the  dis- 
tal end  by  means  of  the  six  threads.  The  latter  are  then  tied  and  four  or 
five  interrupted  sutures  are  passed  through  the  projecting  edge  of  the  distal 
end  and  again  through  the  adventitia  and  media  of  the  proximal  end.  Fi- 
nally, the  sheath  of  the  vessel  is  sutured. 

§  29.  Other  Methods  of  Hsemostasis. — Pressure. — Another  most  im- 
portant method  of  hsemostasis  is  lyressure^  which  we  apply  in  many 
different  ways,  and  which  is  evidently 
the  simplest  and  most  natural  way  of 
checking  haemorrhage.  Whenever, 
during  the  course  of  an  operation, 
blood  gushes  forth  from  a  divided 
vessel,  we  immediately  place  our  fin- 
ger upon  the  bleeding  point  and  so 
stop  the  haemorrhage.  It  is  singular 
that  this  simple  method  of  hsemostasis 
is  so  little  understood  by  the  laity; 
when  they  meet  with  dangerous  bleed- 
ing, perhaps  from  a  punctured  wound 
of  one  of  the  larger  arteries,  they  are 
very   apt    to    employ    the   strangest 

remedies,    snch    as,    for    example,    the      Yig.  96.— Forced  flexion  of  the  kuce  for 
-,,        ,  p         11  1       •      •!  temporary  arrest  of  haemorrhage  in  the 

application   oi    cobwebs   and  similar         popliteal  space. 

things.     Pressure  is  also  practised  as 

a  temporary  means  of  hsemostasis  in  the  form  of  digital  compression 

(mentioned  in  §  18,  p.  54)  of  the  afferent  artery,  and  by  means  of  rub- 


100  THE  METHODS  OF  ARRESTING   HiEMORRHAGE. 

ber  bandages,  tourniquets,  etc.  In  suitable  cases  pressure  can  be  com- 
bined with  forced  flexion  of  the  neighbouring  joint — as,  for  example, 
in  bleeding  in  the  popliteal  space  the  knee  joint  is  immobilised  in  ex- 
treme flexion  (Fig.  96),  or  haemorrhage  at  the  bend  of  the  elbow 
can  be  held  in  check  by  immobilisation  of  the  elbow  joint  in  a  position 
of  extreme  flexion. 

Pressure  is  the  ordinary  method  of  hsemostasis  used  for  stopping 
parenchymatous  bleeding.  The  wound  is  compressed  for  a  time  with 
aseptic  sponges,  or  is  "packed"  with  some  aseptic  material  such  as 
iodoform  gauze,  or  the  dressing  is  bound  on  so  as  to  exert  pressure. 
In  "packing"  a  wound  or  cav^ity  such  as  the  nasopharynx  or  rectum, 
we  fill  it  as  tightly  as  possible  with  some  aseptic  material  such  as  iodo- 
form gauze.  Ligation  of  the  bleeding  vessels  is,  of  course,  much  more, 
reliable  than  this  method. 

Cautery. — Of  the  other  methods  for  hsemostasis  the  hot  iron  is  the 
most  important,  the  best  form  of  which  is  Paquelin's  thermo-cautery 
(•Fig.  73,  p.  79)  or  Middeldorpf's  galvano-cautery  (p.  80).  The  firm 
eschar  of  the  burn  prevents  the  escape  of  blood.  The  cautery  is  usually 
only  suitable  for  bleeding  from  small  vessels  which  cannot  be  ligated. 
It  should  be  used  at  not  more  than  a  red  heat,  so  as  not  to  burn  the 
tissues  too  rapidly,  but  simply  to  char  them  slowly. 

Styptics. — Among-  the  fluid  remedies  for  checking  haemorrhage  men- 
tion should  be  made,  in  the  first  place,  of  liquor  ferri  chloridi,  which  makes  a 
firm  coagulum  with  blood.  A  pledget  of  cotton  or  gauze  is  soaked  in  it  and 
applied  to  the  bleeding  spot  as  firmly  as  possible  for  one  or  two  minutes. 
This  procedure  must  usually  be  repeated  one,  two,  or  three  times.  Styptic 
cotton,  as  it  is  called,  is  simply  cotton  which  has  been  soaked  in  liquor  ferri 
chloridi  and  dried.  The  material  made  from  the  Boletus  igniarius  and  the 
Penghawar  djanibi  is  very  similar  to  styptic  cotton,  and  consists  of  the  light- 
brown  hairs  from  the  stem  of  the  Cibotium  ciiminghii,  an  East  Indian  plant. 
If  this  is  applied  in  sufficient  amount  to  the  wound  surface  and  with  enough 
pressure,  it  makes  a  very  good  styptic.  Noltenius  has  recommended  a  pengha- 
war cotton  consisting  of  a  mixture  of  Penghmcar  djambi  with  cotton  and 
ten  per  cent,  of  iodoform.  All  styptics  producing  an  eschar  pi-event  primary 
union  of  the  wound.  Under  fluid  haemostatics  there  are  still  to  be  mentioned 
vinegar,  solutions  of  alum,  turpentine,  and  aqua  Binelli.  Wright  recom- 
mends a  solution  of  fibrin  ferment  with  one  per  cent,  of  chloride  of  lime  as 
a  useful  li^mostatic,  which  does  not  produce  an  eschar.  Cocaine  has  also  a 
haemostatic  action,  and  for  this  purpose  can  be  used  in  operations  on  the 
gums,  in  bleeding  from  the  nose,  etc.  For  the  latter  purpose  cotton  tampons 
can  be  used  after  soaking  them  iu  a  twenty-  to  thirty-per-ceut.  solution  of 
cocaine  (also  adding  a  little  glycerine).  Saint-Germain  and  Henocque  speak 
well  of  the  haemostatic  action  of  antipyrine  (either  in  a  twenty-per-cent.  solu- 
tion or  in  the  form  of  a  powder).  In  cases  of  haemorrhage  from  the  genito- 
mnnary  tract  Meisels  has  made  successful  use  of  cornutin  (in  doses  of  0.01 


§  30.]  LIGATION   OF  ARTERIES  IN  CONTINUITY,  101 

gramme  a  day).  In  capillary  haemorrhage  Reverdin  recommends  sodium 
sulphate  in  doses  of  a  decigramme  every  hour  as  a  very  excellent  haemo- 
static. 

Cold  and  Hot  Irrigation. — We  arrest  capillary  and  parenchymatous 
hsemorrhage  by  pressure  applied  for  a  short  time,  especially  by  means 
of  aseptic  sponges  or  pads,  by  irrigation  with  ice  water,  or  with  water 
heated  to  about  45°  C.  (113°  F.),  and  by  suturing  the  wound  and  ap- 
plying an  antiseptic  dressing  tight  enough  to  exert  pressure.  Ice  water 
stops  the  bleeding  by  causing  the  capillaries  and  smallest  vessels,  to- 
gether with  the  surrounding  tissues,  to  contract,  while  water  at  a  tem- 
perature of  about  45°  C.  (113°  F.)  acts  by  directly  promoting  coagula- 
tion of  the  blood. 

Suture  of  the  Wound. — An  important  haemostatic  measure,  as  already 
mentioned,  is  the  exact  coaptation  of  the  edges  of  the  wound  by  means 
of  sutures,  especially  in  the  case  of  parenchymatous  bleeding,  and  in 
haemorrhage  from  the  smaller  arteries,  particularly  those  of  the  skin. 

Pressure  from  Dressings. — The  application  of  an  antiseptic  dressing 
which  exerts  pressure  likewise  checks  or  prevents  subsequent  paren- 
chymatous oozing. 

Elevation. — In  the  case  of  the  extremities  we  possess  a  valuable 
haemostatic  measure  in  the  form  of  elevation  or  suspension  of  the  part, 
and  in  certain  cases,  particularly  after  the  use  of  Esmarch's  artificial 
ischsemia,  which  is  apt  at  times  to  be  followed  by  serious  parenchyma- 
tous bleeding  or  oozing,  this  procedure  is  invaluable. 

Ligature  en  Masse. — In  a  ligature  en  masse  a  considerable  portion  of 
tissue  containing  vessels  is  tied  ofP  with  silk  or  catgut.  The  ligatures  are 
carried  through  the  tissues  by  means  of  a  curved  needle  or  a  blunt  aneurism 
needle  (see  Fig.  97,  p.  10.3). 

Acupressure  and  Acufilopressure.— Acupressure  and  acufilopressure  (Simp- 
son)—that  is,  compression  of  the  vessels  by  long  needles  stuck  through  the 
soft  parts  (acupressure),  or  by  needles  thus  inserted  and  having  a  thread 
wound  around  the  projecting  ends  (acufilopressure)— are  at  present  no  longer 
used  and  will  not  be  described. 

§  30.  Ligation  of  Arteries  in  Continuity.— The  ligation  of  arteries  in 
their  continuity  is  performed  for  injuries  and  for  pathological  condi- 
tions, notably  aneurism.  In  case  of  severe  haemorrhage  from  an  artery 
as  the  result  of  a  punctured,  gunshot,  or  transverse  wound,  it  used  to 
be  the  custom  to  ligate  the  artery  at  its  most  accessible  portion,  in  the 
so-called  place  of  election,  proximal  to  the  site  of  injury.  This  is  not 
the  best  plan,  on  account  of  the  frequency  of  secondary  haemorrhage 
from  the  unsecured  wound  in  the  artery  after  the  collateral  circulation 
becomes  established.  At  present  we  search  for  the  point  where  the 
artery  has  been  wounded  and  tie  the  vessel  on  the  proximal  and  distal 


102  THE  METHODS  OP  ARRESTING  HEMORRHAGE. 

sides  of  the  wound,  and  then  extirpate  the  injured  portion  of  the  vessel 
lying  between  the  two  ligatures,  and  secure  any  branches  which  may 
be  given  oU  in  the  immediate  neighbourhood. 

As  described  under  §  18,  the  ligation  of  arteries  in  tlieir  continuity 
is  also  performed  as  a  prophylactic  measure,  to  diminish  or  control 
haemorrhage  during  an  operation  upon  tlie  region  supplied  by  the 
artery  in  question.  Under  this  heading  comes,  for  example,  ligation 
of  the  lingual  arteries  in  extirpation  of  the  tongue,  of  the  femoral  in 
disarticulation  of  the  femur,  of  the  axillary  or  subclavian  in  disarticu- 
lation of  the  humerus.  Moreover,  the  aiferent  arteries  of  a  part  are 
sometimes  ligated  to  check  the  growth  of  an  inoperable  tumour,  and 
for  elephantiasis — for  instance,  of  an  extremity,  etc. 

The  operation,  which  is  performed  with  every  aseptic  precaution, 
consists  of  two  parts :  (1)  The  exposure  and  isolation  of  the  artery, 
and  (2)  the  appKcation  of  the  ligature.  In  general  it  is  best  to  use 
Esmarch's  artificial  ischgemia  in  ligatiug  an  artery  of  an  extremity. 
For  instruments  we  use  a  medium-sized  scalpel,  a  straight  and  curved 
pair  of  scissors,  two  toothed  thumb  forceps,  two  dissecting  forceps, 
several  artery  clamps,  two  retractors,  a  director,  and  an  aneurism 
needle,  with  aseptic  silk  and  catgut  ligatures. 

After  carefully  washing  the  field  of  operation  in  the  usual  way, 
shaving  it,  and  disinfecting  it  with  a  three-per-cent.  solution  of  carbolic 
acid,  or  with  bichloride,  1  to  1,000,  and  placing  the  part  in  a  convenient 
position,  an  incision  six  to  eight  centimetres  long  is  made  through  the 
skin  along  the  course  of  the  artery.  The  fingers  of  the  left  hand  hold 
the  skin  firmly  stretched,  or  a  fold  of  skin  is  lifted  up  and  divided 
from  without  inwards,  or  transfixed  and  cut  from  within  outwards. 
The  skin  is  divided  by  one  stroke  of  the  knife.  Then  the  operator 
and  his  assistant  seize  the  cellular  tissue  at  two  opposite  points  \vith 
toothed  forceps,  and  while  it  is  gently  lifted  up  it  is  divided  between 
the  two  forceps  with  the  knife  to  the  full  extent  of  the  cutaneous  in- 
cision. The  remaining  tissues  are  divided  as  in  dissecting  until  the 
arterial  sheath  is  reached.  The  sheath  can  also  be  reached  very  easily 
and  quickly  by  pushing  aside  and  tearing  the  tissues  with  a  director, 
the  handle  of  the  knife,  or  the  finger.  It  is  advisable  for  the  beginner 
to  divide  the  connective  tissue  carefully  upon  the  director.  When 
the  sheath  of  the  artery  has  been  laid  bare  it  is  well  to  make  certain, 
by  palpation  with  the  finger  tip,  that  it  is  the  artery  which  has  been 
exposed.  Even  though  there  be  no  pulsation,  one  can  easily  distin- 
guish the  firm,  thick  arterial  wall,  which  can  be  made  to  roll  under  the 
finger,  from  the  soft,  thin  wall  of  a  vein.  A  nerve  feels  like  a  round 
solid  cord.     The  operator  then  grasps  the  sheath  of  the  artery  with  a 


§30.] 


LIGATION   OF   ARTERIES   IN   CONTINUITY. 


103 


r 


£ne-toothed.  forceps  or  dissecting  forceps,  lifts  it  up  from  the  artery, 
and  opens  it  with  a  knife  or  curved  scissors  or  a  director.  Into  the 
opening  thus  made  in  the  sheath  of  the  artery  is  inserted  an  aneurism 
needle  or  curved  blunt  hook  (Fig.  97,  «,  J),  in 
order  to  separate  the  artery  itself  on  all  sides 
from  the  sheath.  One  should  never  free  the 
artery  from  its  sheath  to  too  great  an  extent, 
and  one  should  carry  out  this  step  in  the  opera- 
tion as  gently  as  possible,  to  avoid  unnecessary 
laceration  of  the  artery  and  its  sheath.  When 
the  entire  circumference  of  the  artery  has  been 
separated  from  its  sheath,  an  aneurism  needle 
bearing  an  aseptic  catgut  or  silk  ligature  is 
passed  under  the  vessel,  and  after  encircling 
the  latter  the  ligature  is  tied  fast  around  the 
artery  (Fig.  98).  Two  surgeon's  knots  supple- 
mented by  a  simple  knot  are  usually  considered 
necessary  for  the  larger  arteries.  A  surgeon's 
knot  is  made  by  twisting  the  ends  of  the  hga- 
ture  twice  about  each  other,  and  not  once,  as 
in  forming  a  simple  knot.  Large  arteries  are 
usually  secured  by  a  double  ligature,  and  the 
vessel  is  then  divided  between  the  central  and 

peripheral  ligatures.  If  an  artery  is  to  be  tied  double— i.  e.,  on  the 
central  and  peripheral  sides  of  the  point  of  injury,  perhaps  a  punctured 
wound — the  aneurism  needle  is  threaded  with  a  double  ligature,  and 
the  latter,  after  being  placed  around  the  artery,  is  cut  at  the  loop,  thus 
giving  one  ligature  for  the  central  and  the  other  for  the  peripheral 
ligation  of  the  artery.  In  passing  the  aneurism  needle  around  the 
artery  care  must  be  taken  to  avoid  injury  to  the  neighbouiing  vein, 

and   before    drawing   the    ligature 
tight  it  must   be  ascertained   that 
the  artery  alone  is  tied,  and  that  a 
nerve  is  not  included  in  the  liga- 
ture.    After  tying  the  ligature  its 
ends  are  cut  short.     If  the  opera- 
tion has  been  performed  with  the 
aid  of  Esmarch's' artificial  ischemia, 
the  rubber  bandage  is  now   care- 
fully loosened  and  then  slowly  removed.     When  the  double  ligature 
has  been  tied  and  the  intervening  wounded  portion  of  the  artery  has 
been  extirpated,   the  operator  should  always   look  out  for   branches 


Fig.  97. — Aneurism  needles. 


Fig. 


-Ligation  of  an  artery  in  con- 
tinuitv. 


lo-l,  THE  METHODS  OF  ARRESTING  HAEMORRHAGE. 

arising  from  this  interveDing  portion,  which  should  be  secured  with 
the  same  care  as  the  main  vessel,  because  there  is  a  possibility  of  sec- 
ondary haemorrhage  from  these  branches  after  the  establisliment  of  the 
collateral  circulation.  The  wound  is  then  either  packed  with  gauze  or 
closed,  with  or  without  drainage.  An  antiseptic  dressing  exerting  a 
gentle  pressure  must  then  be  applied,  together  with  a  splint  in  the  case 
of  the  extremities,  so  that  the  part  which  has  been  operated  upon  is 
immobilised  as  completely  as  possible.  Immediately  after  the  artery 
has  been  ligated  a  collateral  circulation  takes  place  through  the 
branches  given  off  above  and  below  the  ligature  {see  §  61). 

The  ligation  of  particular  arteries  is  taken  up  in  the  text-book  on 
Regional  Surgery. 

The  ligation  of  veins  in  their  continuity  is  carried  out  in  exactly 
the  same  manner  as  described  for  arteries. 


CHAPTER  YII. 

DRAINAGE    OF   WOUNDS. 

Importance  of  drainage. — Different  methods  of  draining  a  wound  :  leaving  the  wound 
open  ;  aseptic  packing  ;  drainage  by  rubber  tubes. — Absorbable  drains. — Drainage 
tubes  of  glass,  metal,  etc. — Capillary  drainage  with  strands  of  catgut,  horse-hair, 
and  glass  wool. — Formation  of  openings  in  the  skin. — Secondary  suture. — Healing 
under  a  blood-clot  without  drainage  (Schede). 

§  31.  The  Method  of  allowing  the  Secretions  of  a  Wound  to  Escape. — 

Drainage. — In  every  fresh  wound  there  is  regularly  an  escape  of  a 
bloody,  serous  fluid,  rich  in  albumin,  from  the  divided  tissues,  the  open 
capillaries,  and  lymph  spaces,  and  it  corresponds  in  amount  with  the 
size  of  the  wound  and  the  number  of  cavities  and  pockets.  The  forma- 
tion of  these  cavities  in  the  wound  should  be  prevented,  as  far  as  possi- 
ble, by  sutures  and  by  the  application  of  a  dressing  exerting  proper 
pressure.  In  small  wounds  the  pressure  exerted  by  the  dressings  is 
sufficient  to  obtain  rapid  healing,  and  it  is  not  necessary  to  use  means 
for  carrying  off  the  secretion  except  when  suppuration  is  already  pres- 
ent. But  in  case  of  suppuration,  and  in  large  fresh  wounds,  we  must 
provide  suitable  channels  for  the  escape  of  the  secretion  in  the  shape 
of  drainage  in  some  form.  Unless  we  do  this  the  secretion  is  retained 
in  the  wound  and  prevents  primary  union.  Moreover,  opportunity  is 
given  for  the  secretion  to  decompose  and  for  pus  to  form,  and,  as  a 
result  of  the  retention  of  the  pus  or  decomposed  secretion  of  the  wound, 
spreading  suppurative  inflammation  or  general  infection  of  the  whole 
system  takes  place  from  absorption  of  the  infectious  material  (pysemia, 
septicaemia).  Consequently  it  is  a  matter  of  great  importance  to  pro- 
vide careful  drainage  in  large  clean  wounds,  and  particularly  in  those 
which  are  already  infected.  At  the  present  time  attempts  have  been 
made  to  do  away  with  drainage  in  wounds  made  in  aseptic  operations, 
but  most  surgeons  still  rely  upon  it.  As  a  matter  of  fact,  it  is  indis- 
pensable for  the  first  twenty -four  to  forty-eight  hours  in  large  aseptic 
wounds,  even  after  they  have  been  closed  by  sutures — for  example, 
after  amputation  of  the  breast,  accompanied  by  cleaning  out  the  axilla. 
The  secretion  from  the  wound  and  the  effused  blood  can  thus  escape, 

105 


106 


DRAINAGE  OF  WOUNDS. 


and  so  do  not  prevent  the  rapid  agglutination  of  the  opposed  wound 
surfaces.  There  are  various  methods  for  enabling  the  secretion  from 
the  wound  to  escape. 

The  simplest  of  these  is  to  leave  the  wound  open  without  suturing 
it,  or  only  partially  suturing  it,  leaving  the  angles  of  the  wound  unclosed. 
Open,  unsutured  wounds  are  generally  tilled  with  some  absorbent  mate- 


rial, usually    sterile,  or 


iodoform  gauze. 


This  aseptic  packing  of  a 


wound  is  an  excellent  method  of  drainage,  as  it  absorbs  the  secretion 
from  the  wound  and  causes  it  to  remain  aseptic.  When  necessary,  the 
packing  can  be  fastened  in  place  by  sutures  through  the  skin.  Wounds 
which  have  been  left  open  can  then  after  a  few  days,  when  the  pack- 
ing is  removed,  be  closed  by  secondary  suture,  as  it  is  called,  which 
hastens  the  healing  process. 

If  we  wish  to  immediately  close  large  and  deep  wounds,  which  have 
not  been  infected,  so  as  to  obtain  rapid  healing  with  primary  union — 
i.  e.,  direct  agglutination  of  the  tissues  without  the  formation  of  pus, 
as  in  amputations,  resection  of  joints,  extirpation  of  tumours,  etc. — we 
take  proper  steps  for  conducting  off  the  secretions  of  the  wound  by 
drains  inserted  into  the  deepest  portions  of  the  wound. 

Drainage  Tubes. — The  ordinary  drains  are  made  of  tubes  of  vulcan- 
ised rubber  or  glass  provided  with  numerous  lateral  openings  (Figs. 

99  and  100).  These  drainage  tubes 
should  have  as  large  a  calibre  as  pos- 
sible, and,  while  not  being  too  long, 
they  must  always  be  so  inserted  as 
to  render  easy  the  escape  of  the  secre- 
tions from  any  part  of  tlie  wound, 
and  therefore  should  reach  into  its 
deepest  portions.  Whenever  possi- 
ble, I  place  the  drain  to  one  side  of 
the  suture  line  and  not  directly  be- 
neath it,  so  as  not  to  separate  the 
suture  line  from  the  underlying  parts 
and  thus  render  it  impossible  for 
primary  union  to  take  place.  Drains 
are  passed  through  a  wound  with  the 
aid  of  dressing  forceps  (Fig.  101) 
after  the  skin  has  been  first  incised 
with  a  knife  and  the  remaining  soft  parts  have  been  pierced  by  the 
forceps.  The  drainage  tube  is  secured  in  its  position  by  a  stitch  taking 
in  a  j^art  of  the  end  of  the  tube,  or  by  a  disinfected  safety  pin,  and 
thus  prevented  from  slipping  into  the  wound.     T-shaped  tubes  are 


Fig.  99. 

Eubber 

drain. 


Fig.  101.— Drain 
forceps. 


§  31.]     METHOD  OF  ALLOWING  WOUND  SECRETIONS  TO  ESCAPE.      107 

sometimes  useful  in  preventing  the  drain  from  falling  out  of  or  slippino- 
into  the  wound.  A  T-shaped  drainage  tube  is  easily  made  by  splitting 
one  end  of  a  tube  (Fig.  102,  A)  longitudinally  and  then  drawing  each 
end  through  a  lateral  opening  in  another  tube  ( Fig.  102,  £).  The  drain 
is  removed  from  fresh  wounds  at  the  same  time  that  the  stitches  are. 


A  B 

Fig.  102. — Construction  of  a  T-shaped  drainage  tube. 


or  by  the  second,  third,  fourth,  or  seventh  day,  according  to  the 
nature  of  the  case  and  the  size  of  the  wound.  If  it  is  a  suppu- 
rating wound  the  drain  is  taken  out  when  the  suppuration  ceases, 
and  under  such  conditions  it  is  best  not  to  remove  the  drainage  alto- 
gether at  one  time,  but  first  to  shorten  the  tuljes  and  then  graduallv 
take  them  out. 

I  have  recommended  short  drainage  tubes  of  large  calibre  because 
they  do  not  so  easily  become  plugged  up,  and  consequently  there  is  no 
necessity  for  syringing  them  out  with  antiseptic  solutions.  This  syring- 
ing out  of  drainage  tubes  should  be  avoided,  especially  in  all  fresh 
wounds  produced  in  an  operation.  It  can  only  do  harm  by  irritating 
the  wound  and  forcing  apart  again  the  already  adherent  wound  sur- 
faces. It  is  better  to  replace  stopped-up  drainage  tubes,  if  necessary, 
by  new  ones.  Even  washing  out  a  suppurating  wound  with  antiseptic 
solutions  by  means  of  an  irrigator  (Fig.  103)  is  often  entirely  unneces- 
sary, and  may,  indeed,  do  harm. 

Hardening  of  Rubber  Drainage  Tubes. — In  order  to  prevent  rubber  drain- 
age tubes  from  becoming  soft  it  is  a  good  plan  to  first  place  them  for  five 
minutes  (the  thick  variety  longer)  in  strong  sulphui'ic  acid,  then  wash  them 
in  five-per-cent.  alcohol  and  keep  them  in  five-per-cent.  carbolic  or  1  to  1.000 
bichloride.  The  orange-red  drainage  tubes  are  best  suited  to  this  process, 
the  gray  and  black  ones  less  so.  The  tubes  that  have  once  been  hardened 
retain  the  stiffness  of  their  walls  even  in  the  antiseptic  solutions  in  which 
they  are  kept  stored. 


108  DRAINAGE  OF   WOUNDS. 

Absorbable  Drainage  Tubes. — Besides  rubber  drainage  tubes,  other  forms 
have  been  used,  such  as  absorbable  tubes  made  of  decalcified  bone.  The 
absorbable  drainage  tubes  of  decalcified  bone  have  not  come  into  very  gen- 
eral use,  because  they  are  liable  to  be  absorbed  too  quickly  before  they  have 
accomplished  their  purpose. 

Preparation  of  Absorbable  Bone  Drains.— Absorbable  bone  drainage  tubes 
are  made  as  follows :  The  long,  hollow  bones  of  fowls  and  other  birds  are 
freed  from  soft  parts  by  boiling,  and  then  placed  for  about  ten  or  twelve 
hours  in  a  mixture  of  one  part  of  hydrochloric  acid  and  two  parts  of  water; 
the  ends  of  the  bones  are  cut  off  with  scissors  and  their  interior  cleaned  out 
Avith  a  stout  wire,  after  wliich  they  are  boiled  in  a  five-per-cent.  carbolic  solu- 
tion, to  which  Deakiu  adds  some  borax,  and  they  are  finally  stored  for  use 
in  the  same  solution. 

Strands  of  Catgut  as  a  Drain.  —  The  smallest  drain  which  we 
use  consists  of  strands  of  aseptic  catgut  or  horse-hair,  which  are 
laid  side  by  side  in  the  form  of  a  bundle  of  threads.  Kumniel  has 
recommended  capillary  glass  drainage  in  the  form  of  strands  of  spun 
glass. 

Attempts  have  been  made  to  substitute  drainage  by  means  of  holes 
made  in  the  skin  for  the  ordinary  drainage  with  rubber  tubes  in  case  of 
wounds  directly  under  the  skin,  and  the  canalisation  of  skin  and  mus- 
cular tissue  in  case  of  deeper  wounds  (Esmarch  and  Neuber).  To  make 
a  canal  of  skin  and  muscular  tissue  for  purposes  of  drainage,  the  cut 
edge  of  the  skin  on  each  side  is  attached  by  a  catgut  suture  to  the 
wound  in  the  muscular  tissue  beneath  it. 

Of  all  these  different  kinds  of  drainage,  in  my  judgment  the  ordi- 
nary drainage  supplied  by  rubber  or  glass  tubes,  or  by  packing  the 
wound  with  sterilised  gauze,  is  by  far  the  best,  and  all  other  methods 
(strands  of  catgut,  bundles  of  horse-hair,  cutaneous  punctures,  canalisa- 
tion, and  absorbable  drains)  are  only  suitable  for  small  wounds,  and  are 
insufficient  for  large,  deep  wounds  in  which  there  are  pockets.  If  the 
drainage  by  rubber  tubes  is  properly  managed  and  the  drains  removed 
at  the  right  time,  it  is  easy  to  prevent  the  evil  consequences  which  the 
tubes  sometimes  cause,  such  as  necrosis  of  the  skin,  persistent  fistulae, 
etc.  "With  a  view  to  diminishing  the  amoimt  of  secretion  in  the  wound 
it  is  very  important  that  the  same  should  be  irritated  as  little  as  pos- 
sible by  antiseptics.  Consequently  we  should  operate  by  the  aseptic 
method  and  keep  the  wound  dry. 

Kocher's  Substitute  for  Drainage.— Kocher  has  tried  to  dispense  with 
the  drainage  of  the  wound  by  covering  it  with  a  thin  layer  of  subuitrate  of 
bismuth.  The  latter  is  sprinkled  over  the  wound  in  the  form  of  a  one-per- 
cent, mixture  of  bismuth  in  water,  which  is  dropped  out  of  a  flask ;  or,  if 
there  is  bleeding,  compresses  impregnated  with  bismuth  are  applied  to  the 
wound.     The  wound  surface  is  so  much  dried  up  by  the  bismuth  that  the 


§  31.]     METHOD  OF  ALLOWING  WOUND  SECRETIONS  TO  ESCAPE.      109 

secretion  is  almost  nil.     After  twelve,  twenty-four,  or  forty-eight  hours  the 
wound  is  closed  by  secondary  suture. 

Schede's  Method  of  healing  under  a  Blood-clot.— Schede  has  recently 
recommended  "healing  under  a  moist  blood-clot" — e.  g.,  he  permits  a  cavity 
which  has  been  hollowed  out  of  a  bone  to  fill  with  blood,  closing  the  wound 
tight  by  suturing  the  skin  and  not  inserting  any  drain.  If  the  coagulum 
thus  formed  in  the  course  of  an  aseptic  operation  remains  aseptic,  it  will  be 
gradually  absorbed  and  its  place  taken  by  newly  formed  connective  tissue  or 
bone,  and  healing  will  occur  without  reaction.  I  think  this  method  deserves 
a  fair  trial ;  it  has  proved  of  service  to  me  after  operations  for  caries  and 
necrosis. 


CHAPTEE  YIII. 


SUTTTEE    OF    THE    WOU^TD. 


Disinfection  of  the  wound  and  surrounding  parts  before  inserting  the  sutures. — Suture 
of  the  soft  parts. — Needles,  needle  holders,  and  suture  materials. — Different  meth- 
ods of  suturing  the  wound  (interrupted,  continuous,  silver-wire  suture,  plate 
suture,  twisted  suture). — Removal  of  the  sutures. — Secondary  suture. — Bloodless 
suture. — Subcutaneous  suture  of  nerves,  tendons,  muscles,  etc. — Union  of  wound 
surfaces  in  bones  (bone  suture). — Suture  of  the  periosteum. — Nailing  and  other 
methods  of  uniting  the  surfaces  of  a  divided  bone. 

§  32.  Disinfection  of  the  Wound  before  inserting  the  Sutures.— After 
arresting  the  lisemorrhage  very  carefully  and  putting  in  the  proper 
drainage,  the  wound  and  the  surrounding  parts  are  washed  with  a 
three-per-eent.  solution  of  carbolic  acid  or  1  to  1,000-5,000  solution 
of  bichloride  of  mercury.  The  irrigator  (Fig.  103)  is  best  suited  for 
this  purpose ;  it  is  made  of  metal — or,  better,  of  glass — with  a  rubber 

tube  provided  with  a  remov- 
able tip  made  of  glass  or  rub- 
ber, through  which  the  solu- 
tion flows.  A  warning  must 
be  given  against  too  vigoi'ous 
cleansing  of  the  wound  with 
antiseptics,  because  too  much 
irritation  is  produced,  and  the 
ensuing  secretion  from  the 
wound  will  be  increased.  I 
irrigate  \vounds  made  during 
an  operation  only  in  those  cases 
in  which  there  is  the  possibility 
of  infection  having  occurred  during  the  operation.  Even  when  a 
wound  is  already  infected  and  pus  is  present  the  strong  antiseptic  solu- 
tions should  be  avoided.  It  is  sufficient  to  cleanse  the  wound  with 
weak  solutions  or  sterile  salt  solution,  particularly  as  it  is  impossible  to 
really  disinfect  by  antiseptics  a  wound  that  has  become  infected,  as  the 
pathogenic  micro-organisms  present  in  the  tissues  are  not  killed  thereby. 
110 


Fig.  103. — Irriscator. 


33.] 


THE  UNITIiSrG   OF  THE  SOFT   PARTS. 


Ill 


If  there  are  no  irrigators  at  hand,  clean  aseptic  sponges  or  gauze  pads 
may  be  soaked  full  of  the  antiseptic  solution  or  sterile  water  and 
squeezed  out  over  the  wound  and  adjoining  parts.  I  keep  the  wound 
as  dry  as  possible,  but  if  it  is  necessary  to  wash  out  the  wound  I  use 
sterile  water  or  salt  solution.  If  this  is  done  the  secretion  in  the 
wound  is  much  less  than  when  the  irritating  antiseptic  solutions  are 
used.  The  main  point  is  always  to  operate  with  perfectly  aseptic 
hands  and  instruments.  When  the  haemorrhage  has  been  arrested  and 
the  wound  treated  on  these  general  principles,  we  proceed  to  insert 
the  sutures. 

§  33.  The  Uniting  of  the  Soft  Parts— Suture  of  the  Wound. — In  all 
cases  in  which  we  wish  to  obtain  as  speedy  union  of  the  wound  as 
possible  (yper  jprhnam  intsntionem)  we  close  the  wound  by  suturing 
together  its  edges.  Suturing  should  always  be  carried  out  with  the 
same  regard  to  asepsis  as  was  had  in  the  operation  itself,  and  hence 
the  needles  and  the  sutures  must  be  previously  made  aseptic. 

I' 'or  introducing  sutures  we  use  straight  and  variously  curved  nee- 
dles with  lance-shaped  points.     The  recently  introduced  platinum-iris 


Fig.  104. — Needle  holders. 

needles  possess  the  advantage  of  not  oxidising,  and  they  can  be  heated 
red-hot  without  losing  their  original  temper.  Besides  the  ordinary 
needles  without  handles,  there  are  many  provided  with  handles  (I  only 
use  these  in  performing  uranoplasty  and  staphylorrhaphy).  When  the 
needle  cannot  be  mtroduced  by  hand,  as  in  the  mouth  or  pharynx,  the 


112  SUTURE   OF   THE   WOUND. 

vagina,  etc.,  we  use  a  needle  holder.  Of  the  numerous  different  kinds 
of  needle  holders,  those  worthy  of  mention  are  the  holders  of  Dieffen- 
bach,  Reiner  (Fig.  104,  a),  Eoux  (Fig.  104,  b\  Sims  (Fig.  104,  e), 
Hagedorn  (Fig.  104,  d),  and  others. 

Suture  Material. — Sutures  are  made  of  sterilised  silk,  linen  thread, 
catgut,  horse-hair,  sea-grass,  silkworm  gut  (from  the  chrysalis  of  the 
silkworm  I,  erin  de  Florence  (from  the  intestine  of  the  silkworm),  silver 
wire,  aluminium-bronze  wire,  etc.  Catgut  has  the  great  advantage 
over  silk  that  it  is  absorbable,  and  is  therefore  preferable  for  subcu- 
taneous or  buried  sutures — that  is,  suture  of  nerves,  tendons,  muscles, 
etc.  Moreover,  buried  catgut  sutures  are  the  best  for  uniting  a  rup- 
tured perinseum  ;  for  the  radical  cure  of  hernia  ;  for  operations  on  the 
uterus,  bladder,  or  intestine  ;  and  for  operations  on  fistulas.  If  catgut 
is  used  for  suturing  the  skin,  the  sutures  will  not  need  to  be  removed 
with  scissors,  but  after  about  four  to  seven  days  the  external  portion 
lying  over  the  line  of  the  wound  can  be  simply  picked  off  with  for- 
ceps, as  the  part  which  lies  buried  in  the  tissues  is  absorbed,  or  is  only 
very  weakly  attached  to  the  rest  of  the  suture.  On  account  of  this 
rapid  absorption  of  catgut,  it  follows  that  under  certain  conditions  cat- 
gut sutures  will  not  hold  the  borders  of  the  wound  long  enough  in 
apposition.  I  generally  use  fine  silk  in  suturing  the  skin.  The  prepa- 
ration of  a  satisfactory  catgut  has  been  described  on  pages  94-97. 
The  size  of  the  catgut  or  silk  suture  required  will,  of  course,  depend 
upon  the  kind  of  tissues  to  be  united  and  the  amount  of  tension. 
When  there  is  great  tension  strong  sutures  are  naturally  required,  be- 
cause fine  sutures  would  easily  cut  through. 

Silver  N\dre  should  be  made  smooth  before  use  by  passing  it 
through  a  flame  till  it  becomes  red-hot.  Silkworm  gut  is  excellent 
for  tying  off  the  pedicle  in  ovariotomy,  for  perineal  operations,  etc. 
In  place  of  silver  wire  I  have  been  using  of  late  Socin's  aluminium- 
bronze  wire,  which  is  cheaper,  more  pliable,  and  more  resistant  than 
silver. 

Sutures  made  from  the  Tendons  of  Reindeer,  Horses,  and  Deer.— Ratiloff 

uses  the  tendons  of  reindeer  for  sutui^ing  wounds.  This  material  is  used  by 
the  Siberian  colonists  for  sewing.  Putilow  uses  the  tendons  of  horses  and 
deer.  The  strips  of  tendon  are  soaked  for  twenty-four  hours  in  ether,  and 
for  the  same  length  of  time  in  a  five-per-cent.  alcoholic  solution  of  carbolic 
acid.  The  strips  of  tendon  thus  prepared  are  said  to  be  stronger  than  catgut, 
as  soft  as  silk,  and  completely  absorbed  in  the  wound. 

The  Interrupted  Suture. — The  most  common  form  of  suture  is  the 
so-called  interrupted  suture  (Fig.  105).  This  is  introduced  with  straight 
or  curved  needles,  the  aseptic  catgut  or  silk  being  simply  knotted  in 


§33.]  THE  UNITING   OF   THE  SOFT   PARTS.  113 

the  eye  of  the  needle,  or,  better,  threaded  so  as  to  leave  two  long  ends. 
The  knot,  especially  if  the  suture  is  of  large  size,  interferes  with  draw- 
ing the  eye  portion  of  the  needle  through  the  skin.     The  border  of 
the  wound  is  seized  with  a  toothed  forceps,  and  the 
needle   is  pushed   through   first   one   edge   of  the         :-^^  '  |!''p 
wound   and   then   the   other.     Both  edges   of  the  — _E-^    % 

wound  can  be  pierced  at  the  same  time,  provided 
they  are  held  together  by  an  assistant.  The  knots 
should  be  placed  to  one  side  of  the  line  of  suture.    If  -Ji—/^^^  "^^ 

there  is  much  tension  on  the  edges  of  the  wound  the  [      ^--^ 

so-called  surgeon's  knot  is  occasionally  used — that  \      {   jm 

is,  the  ends  of  the  suture  are  twisted  not  once,  but  — ^ — ^  ft 

twice   about  each  other.     It  is  best  to  begin  the  f 

suture  not  at  the  ends  of  the  wound,  but  in  the  - 

middle,  especially  if  it  is  a  long  one ;  and  at  the     ^'''-  ^''t;;;^ure''"^^^''*^ 
time  of  inserting  the  first  suture  care  should  be  taken 
to  have  the  borders  of  the  wound  in  good  apposition,  as  otherwise 
troublesome  folds  at  the  extremities  of  the  line  of  suture  may  result. 

Two  different  kinds  of  sutures  are  classed  under  the  head  of 
interrupted  sutures :  the  tension  suture  and  the  coaptation  suture. 
The  first  is  inserted  and  brought  out  anywhere  from  one  to  six  centi- 
metres from  the  edges  of  the  wound,  while  the  second  or  coapta- 
tion suture  is  shorter,  and  the  points  where  it  enters  and  emerges 
are  only  about  half  a  centimetre  distant  from  the  edges  of  the  wound 
(Fig.  105). 

Those  sutures  by  which  correct  apposition  of  the  borders  of  a  long 
wound  are  obtained  are  called  apposition  sutures.  In  every  suture  line 
the  greatest  care  is  necessary  to  prevent  the  edges  of  the  wound  from 
becoming  inverted,  and  the  two  borders  must  lie  in  good  apposition 
with  each  other.  The  sutures  must  not  be  drawn  too  tight.  It  must 
constantly  be  borne  in  mind  that  the  successful  healing  of  a  sutured 
wound  depends  upon  the  proper  insertion  of  the  sutures,  and  that 
sutures  applied  unskilfully  and  without  antiseptic  precautions  may 
give  rise  to  serious  dangers.  An  erysipelas  which  may  cause  the  death 
of  the  patient  may  start  from  a  small  spot  of  necrosis  in  the  skin,  aris- 
ing, perhaps,  from  a  portion  of  the  border  of  the  wound  which  has 
got  turned  in,  if  the  borders  of  the  wound  are  not  properly  placed  in 
apposition  ;  or  it  may  start  from  a  small  stitch  abscess  produced  by 
an  imperfectly  disinfected  needle  or  suture.  Disastrous  results  may 
follow  from  very  small  causes.  Furthermore,  no  appreciable  cavity 
should  be  allowed  to  remain  ;  and  hence  the  deejDer-l^ang  parts  are 
sometimes  united  by  special  catgut  sutures  or  are  included  in  the  cuta- 
9 


114 


SUTURE  OF  THE   WOUND. 


neous  sutures.     "  Good  suturing,  good  healing,"  was  a  favourite  saying 
of  Xussbaum. 

Continuous  Suture. — Instead  of  the  ordinary  interrupted  suture  I 
fre(|uently  use  the  continuous  suture,  and  usually  in  combination  with 
tension  sutures  (Fig.  106).  I  use,  whenever  it  is  possible,  needles  with 
lance-shaped  points,  of  the  same  size  as  the  ordinary  tailors'  needles. 
The  fine  suture,  which  should  not  be  too  long,  is  simply  knotted  in  the 
eye  of  the  needle.  The  number  of  tension  sutures  required  depends, 
of  course,  upon  the  length  of  the  wound.  The  tension  sutures  are 
inserted  in  the  usual  way,  and  then  the  continuous  suture  is  begun  at 
one  end  of  the  wound  by  making  one  ordinary  interrupted  suture ;  the 
thread,  however,  is  not  cut,  but  the  suture  is  continued  by  transfixing 
at  equal  distances  the  opposed  borders  of  the  wound,  which  are  held 

together  by  the  fingers.  When 
the  other  end  of  the  wound  is 
reached  (Fig.  106,  a)  the  suture 
is  cut  with  scissors,  and  the  three 
threads  are  knotted  together 
like  the  ordinary  interrupted 
suture,  two  threads  being  on 
one  side  of  the  wound  and  one 
upon  tlie  other.  The  suture  can 
also  be  finished  off  by  forming 
a  loop  through  which  the  ex- 
tremity of  the  suture  is  drawn. 
The  continuous  suture  has  the 
advantage  over  every  other  kind  of  being  capable  of  very  rapid  execu- 
tion, and  of  rendering  excellent  coaptation  of  the  borders  of  the 
wound.  If  the  wound  is  very  long  and  there  is  fear  that  a  single  con- 
tinuous suture  will  not  be  strong  enough,  the  suture  can  be  interrupted 
at  any  desired  part  of  the  wound,  and  from  this  point  a  fi-esh  continu- 
ous suture  can  be  begun ;  or  it  can  be  given  greater  security  by  tying 
it  at  any  point  and  then  continuing.  But  when  the  precaution  of 
inserting  tension  sutures  is  taken  there  need  be  no  fear  that  the  con- 
tinuous suture  will  prove  at  all  untrustworthy  if  it  is  carefully  inserted. 
Catgut  is  ordinarily  the  best  material  for  the  continuous  suture,  and 
I  use  aseptic  silk  for  the  tension  sutures.  The  continuous  suture  is 
particularly  adapted  for  operations  on  the  peritonseum  and  the  gastro- 
intestinal tract,  and  for  the  buried  catgut  suture  in  operations  on  the 
vagina  for  prolapse  and  for  rupture  of  the  perinseum. 

Subcutaneous  Suture.— In  order  to  prevent  stitch-hole  suppuration  some 
surgeons  use  the  subcutaneous  suture,  which  consists  in  passing  the  needle 


Fig.  106. — Continuous  suture. 


§33.] 


THE   UNITING   OF   THE   SOFT   PAKTS. 


115 


through  the  cutis  parallel  to  the  surface,  as  the  purse-string  suture.  In  this 
way  the  outer  layers  of  the  skin  and  the  ducts  of  the  skin  glands  which  con- 
tain bacteria  are  not  penetrated  by  the  needle.  The  ends  of  the  suture  are 
tied  at  each  angle  of  the  wound  over  a  small  gauze  roll. 

Silver-wire  Sutures. — If  silver  wire  is  used  for  suturing,  it  is  fas- 
tened to  a  straight  or  curved  needle  by  simply  bending  over  one  end 
of  the  wire  after  it  is  threaded  through 
the  eye.  The  silver-wire  suture  is  fas- 
tened in  place  by  exerting  suitable  trac- 
tion on  the  wire  and  then  simply  twist- 
ing together  its  crossed  ends,  or  an 
instrument  particularly  designed  for  the 
purpose  may  be  used  (Fig.  107).  The 
cross-piece  of  the  "  wire  twister  "  con- 
tains two  round  openings  into  which 
the  ends  of  the  wire  are  passed  after 
they  have  been  crossed  over  the  wound, 
and  then  by  rotating  the  instrument  the       Fig.  io7. 

.      .    .     ^  ^  1,1  Wire  suture 

Wires  are  twisted  around  each  other.  tio-htener. 


Fig.  lOS.— Lead 
plates. 


The  SHver-wire  Suture  with  the  Lead  Plate.— A  form  of  tension  suture 
which  has  at  present  somewhat  gone  out  of  use  is  the  silver- wire  lead- plate 
suture  used  for  closing  the  wound  after  abdominal  section  or  amputation  of 
the  breast.  Small  lead  or  glass  plates  are  requii'ed  which  are  perforated  in 
the  centre.  The  silver  wire  is  either  twisted  around  the  plate  (as  in  Fig.  108, 
a),  or  fastened  to  pins  on  its  surface  (Fig.  108,  6),  or  else  the  silver  wire  is 
inserted  in  a  small  lead  ring  which  is  pinched  together  with  forceps.  Glass 
beads  can  also  be  used.  The  end  of  the  wire  is  passed  twice  through  the  bead 
and  drawn  tight,  then  through  the  lead  plate,  and  after  attaching  it  to  a 
needle  the  suture  is  inserted.  Upon  the  other  side  of  the  wound  the  wire  is 
first  passed  through  the  lead  plate,  then  through  one  or  more  glass  beads, 
and  after  obtaining  the  proper  tension  the  wire  is  twisted  around  a  sterilised 

match  and  the  ends 
are  cut  short  with 
scissors.  It  is  a  very 
good  plan  to  use,  in- 
stead of  silver  wire, 
a  double  silk  suture 
and  tie  the  two  ends 
on  each  side  over  a 
glass  bead,  only  one 
thread  passing  through  the  bead.  Pledgets  of  iodoform  gauze  can  also  be 
used  for  securing  the  ends  of  the  silver-wire  lead-plate  suture.  At  present  I 
have  given  up  this  kind  of  suture,  and  prefer  a  tension  suture  of  stout  ster- 
ilised silk  inserted  .some  distance  from  the  edge  of  the  wound.  The  latter, 
furthermore,  is  more  quickly  inserted. 


Fig.  109. — Fisrure-of-eisrht  suture. 


116  SUTURE   OF   THE  WOUND. 

Other  Methods  of  Suturing.— The  old-fashioned  continuous  furrier's  stitch, 
the  tin  stitcli,  and  the  looped  suture  are  useless  and  out  of  date,  and  will  not 
be  described.  The  continuous  suture  which  I  have  described  differs  materi- 
ally from  the  continuous  furrier's  stitch.  The  so-called  "figure-of-eight'"  or 
twisted  suture  (Fig.  109)  I  also  consider  vmnecessary,  and  no  longer  use  it. 
The  interrupted  suture  answers  the  same  pui-pose,  is  more  simply  inserted, 
and  is  better  for  the  tissues.  It  is  applied  in  the  following  way  :  The  edges 
of  the  wound  are  transfixed  by  long  Carlsbad  needles  some  distance  apart. 
About  the  ends  of  the  needles  is  twisted  an  aseptic  silk  suture  in  the  form  of 
a  circle  or  figure  of  8,  and  the  extremities  of  the  thread  ai*e  knotted  together. 
The  sharp  ends  of  the  needle  are  clipped  off  with  a  Luer's  rongeur  forceps. 

The  Removal  of  Sutures. — The  stitches  are  taken  out,  in  the  majority 
of  cases,  at  any  time  from  the  tliird  to  the  seventh  day,  according  to  the 
kind  of  wound.  AVe  frequently — for  instance,  after  plastic  operations 
on  the  face — take  out  a  stitch  here  and  there  at  the  end  of  twenty-four 
hours ;  but  in  other  cases,  on  the  contrary,  as  when  the  peritoneal  cav- 
ity has  been  opened,  we  allow  the  stitches  to  remain  till  the  eighth  to 
the  fourteenth  day.  In  long  wounds,  and  in  those  in  which  there  is 
danger  of  the  agglutinated  borders  of  the  wound  separating  after 
removal  of  the  sutures,  the  latter  should  not  all  be  taken  out  at  the 
same  time.  The  tension  sutures,  particularly  at  the  extremities  of  the 
wound,  when  combined  with  the  continuous  suture,  should  be  taken 
out  first.  If  the  tension  sutures  become  buried  in  the  skin — i.  e.,  "  cut 
out " — they  should  be  removed  immediately.  Sutures  are  removed  by 
seizing  one  end  of  the  knot  with  dissecting  forceps  and,  while  slight 
traction  is  exerted,  cutting  off  the  suture  close  to  the  wound  and  care- 
fully drawing  it  out.  Care  must  be  taken  that  the  whole  suture  is 
removed.  If  catgut  has  been  used  it  is  unnecessary  to  cut  the  stitches 
with  scissors,  as  the  portion  buried  in  the  tissues  is  absorbed,  and  only 
leaves  the  exposed  loop  of  catgut  to  be  picked  oft'  the  skin  with  thumb 
forceps. 

Secondary  Suture. — If  the  bordei^s  of  the  wound  gape  after  removal  of 
the  stitches,  the  wound  can  be  reunited  by  a  fresh  suture  (secondary  suture). 
This  secondary  suture  is  very  much  used — for  example,  in  wounds  which 
have  been  first  packed,  or  in  wounds  which  have  been  left  entirely  open 
during  the  first  few  days,  or  in  deep,  granulating  wounds,  etc.  To  avoid  a 
repetition  of  the  anaesthesia  when  secondary  sutures  are  applied,  Nussbaum 
has  advised  that  the  secondary  suture  be  put  in  place  at  the  time  of  the  first 
operation.  For  example,  a  mattress  or  continuous  suture  should  be  inserted 
in  advance  in  each  margin  of  the  wound,  and  then,  later,  the  loops  of  these 
sutures  can  be  used  to  close  the  wound  by  passing  a  silk  thread  through 
them. 

Stitch-hole  Suppuration.— Stitch-hole  abscesses  are  caused  in  part  by  the 
bacteria  in  the  skin  and  cutaneous  glands  whose  presence  is  due  to  incom- 
plete sterilisation  of  the  field  of  operation,  and  in  part  by  the  use  of  non- 


;34.]     THE  METHOD  OF  UNITING  WOUND  SURFACES  OF  BONE.       II7 


sterile  needles  and  sutures.  In  putting  in  buried  sutures,  the  latter  should 
not  be  too  numerous  nor  drawn  too  tight,  as  necrosis  followed  by  suppura- 
tion may  easily  result.  Catgut  sutures  made  from  poorly  prepared  material 
containing  toxines  may  cause  non-bacterial  suppuration.     (Poppert.) 

Bloodless  Suture. — The  bloodless  or  dry  method  of  suture  has  gone 
entirely  out  of  use.  The  Arabs  used,  for  closing  a  wound,  an  insect  iSca- 
rites  pyrcemon)  whose  maxilla  terminated  in  a  small  hook.  The  borders  of 
the  wound  were  approximated  by  these  hooks,  the  body  of  the  insect  being 
removed  and  leaving  only  the  head  with  its  hooks.  Vidal  de  Cassis 
attempted  to  imitate  this  method  of  approximation  with  his  serre-fine. 

The  suture  of  tendons,  nerves,  etc.,  is  described  in  the  third  section 
(§  88,  Injuries,  Wounds),  and  suture  of  the  intestine,  bladder,  etc.,  is 
treated  in  the  text-book  on  Regional  Surgery. 

§  34.  The  Method  of  uniting  Wound  Surfaces  of  Bone. — The  sur- 
faces of  a  wound  in  a  bone  can  be  held  in  apposition  by  periosteal 
sutures  only  when  small  bones  are  concei-ned.  A  suture  passed 
through  the  bone  itself  is,  of  course,  the  best.  The 
necessary  holes  are  made  through  the  bone  by  means 
of  the  dental  boring  machine  (Fig.  90,  p.  89),  the 
electromotor  (Fig.  91,  p.  90),  or  a  bone  drill  (Fig. 
110).  The  latter  is  worked  by  pushing  the  metal  spool 
on  the  instrument  up  and  down  and  thus  causing  the 
needle  to  rotate.  Heavy  catgut,  silver  wire,  or  alumin- 
ium -  bronze  wire  are  used  as  suture  materials.  J. 
Henequin  (Rev.  de  Chir.,  August,  1892)  and  Y.  Wille 
(Centrbl.  fiir  Chir.,  1892,  p.  46)  have  recommended  a 
very  good  method  of  bone  suture.  Wille's  plan  con- 
sists in  boring  a  hole  through  both  walls  of  a  hollow 
bone  and  dragging  the  silver  wire  through  it  by  means 
of  a  peculiar  "  suture  hook."  Dollinger  recommends 
a  method  of  bone  suture  without  making  holes  in  the 
bone.  He  winds  a  piece  of  wive  about  each  end  of 
the  broken  bone  and  then  fastens  the  bones  together 
by  two  longitudinal  pieces  of  silver  wire  which  he 
attaches  to  the  circular  wires. 

Another  excellent  method  of  uniting  the  surfaces  of  a  wound  in 
bone  is  aseptic  nailing.  Long,  four-cornered  nails  are  used,  which 
are  first  very  carefully  polished  and  then  sterilised  by  boiling  in  a  five- 
per-cent.  carbolic-acid  solution.  After  some  three  or  four  weeks  the 
loosened  nails  can  be  easily  drawn  out  with  forceps  or  the  fingers  and 
without  causing  the  patient  pain.  Of  course,  care  must  be  taken  that 
the  nails  project  at  least  two  centimetres  beyond  the  level  of  the  skin. 
Long  ivory  pegs  are  sometimes  used  instead  of  metal  nails ;   but  I 


Fig.  110.— Drill  for 
bone  sutures. 


118  SUTURE  OF  THE  WOUND. 

have  found  tliat  ivorj  pegs  are  not  so  easily  removed  as  iron  nails, 
as  the  outer  surface  becomes  rough  from  contact  with  the  tissues, 
especially  bone.  The  ivory  pegs  become  decalcified  by  the  action  of 
the  carbonic  acid  in  the  tissues,  and  the  remaining  organic  jjortion  is 
dissolved,  thus  producing  small  pockets  and  cavities  into  which  the 
surrounding  bone  grows.  The  aseptic  nailing  together  of  the  surfaces 
of  a  wound  in  bone,  as  after  resections,  particularly  of  the  knee  and 
ankle,  in  fractures,  separation  of  the  epiphyses,  etc.,  is  entirely  devoid 
of  danger  if  the  operation  is  performed  with  the  strictest  antiseptic 
precautions. 

For  fastening  together  a  divided  bone,  as  in  separation  of  the 
epiphysis  at  the  upper  end  of  the  humerus,  Helferich  has  recommended 
long,  awl-like  steel  needles,  fitted  with  a  handle  w^hicli  unscrews.  These 
are  made  to  slowly  bore  their  way  into  the  bone.  After  eight  to  four- 
teen days  the  needles  are  removed. 

Special  clamp  apparatus  have  been  devised  for  uniting  bone  sur- 
faces (Gussenbauer,  Parkhillj.     Screws  may,  for  exam^^le,  be  inserted 

into  both  fragments,  and  the  two 
projecting  ends  of  the  screws  con- 
nected by  some  form  of  clamj). 
Under  fractures  we  shall  become 
acquainted  with  Malgaigne's 
,,,„„.       ,,  ,        ,     ^,        ,  hooks  and  Langen beck's  screw. 

iiG.  111. — Union  ot  the  ends  of  bones  bv  -^  j-   j-  -r, 

implantation.  ^         in  cases  01  fracture  Bircher  has 

recently  introduced  the  practice 
of  inserting  an  ivory  peg  into  the  open  ends  of  the  medullary  cavity 
of  the  diaphysis,  and  of  using  ivory  clamps  for  holding  in  contact 
fractures  involving  the  epiphyses.  In  part  of  the  cases  the  wound 
healed  up  over  the  ivory  peg ;  in  sixteen  cases  (out  of  thirty -five)  the 
peg  had  to  be  subsequently  extracted. 

Another  method  of  uniting  bone  surfaces  is  illustrated  in  Fig. 
111.  The  somewhat  pomted  extremity  of  one  fragment  (the  femur)  is 
inserted,  for  instance  after  resection  of  the  knee,  into  the  medullary 
cavity  of  the  other  fragment  of  bone  (in  this  case  the  tibia). 

The  treatment  of  defects  in  bone  is  described  in  ^  43  and  §  101. 


CHAPTEE  IX. 

AMPUTATIONS,    DISARTICULATIONS,    AND    EESECTIONS. 

Performance  of  amputations  and  disarticulations. — Subperiosteal  amputations  and  dis- 
articulations.— History  of  the  methods  of  amputation  and  disarticulation. — After 
treatment. — Bad  sequelae. — Infection  of  the  wound. — Muscular  spasm. — Secondary 
hfemorrhage. — Gangrene  of  the  flaps. — Xeerosis  of  the  stump  of  the  bone. — Coni- 
cal stump.— iSTeuralgia.— Neuromata.— Fatal  results. — Mortality  statistics.— Artifi- 
cial limbs. — The  methods  of  performing  resection. 

§  35.  General  Considerations  in  performing  Amputations  and  Disartic- 
ulations.— By  amputation  (from  amputare,  to  cut  oif)  is  understood 
the  operative  removal  of  an  entire  portion  of  an  extremity.  If  a  limb 
is  severed  through  a  joint  the  operation  is  called  a  disarticulation,  in 
contradistinction  to  amputation,  in  which  the  portion  of  the  limb 
removed  is  cut  off  by  sawing  through  the  bone  in  its  continuity.  Am- 
putation is  not  confined  to  the  extremities  alone,  but  is  used  to  desig- 
nate the  removal  of  certain  portions  of  the  tnink,  like  amputation  of 
the  breast,  the  penis,  or  the  cervix.  "We  shall  discuss  here  only  ampu- 
tations and  disarticulations  of  the  extremities. 

The  Indications  for  Amputation  and  Disarticulation  have  markedly  de- 
■creased  in  modern  surgery,  which  leans  more  and  more  towards  conserva- 
tive methods  of  treatment.  With  the  aid  of  the  antiseptic  methods  we  are 
now  often  able  to  save  a  limb  which  formerly,  in  the  preantiseptic  era,  woidd 
have  fallen  a  prey  to  the  mutilating  effects  of  amputation  and  disarticulation. 
We  shall  entirely  omit  a  detailed  description  at  this  point  of  the  indications 
for  amputation  and  disarticulation,  as  there  will  be  oppoi^tuuity  enough  for 
discussing  this  subject  when  we  take  up  special  diseases  and  injuries.  It  is 
suflBcient  to  state  here  that  these  operations  are  indicated  in  all  diseases  and 
injuries  of  the  extremities  which  threaten  to  destroy  the  whole  limb  or  the 
life  of  the  patient,  and  hence  in  (1)  extensive  injury  to  the  soft  parts  and 
bone  which  precludes  the  possibility  of  saving  the  extremity  in  question,  or 
renders  the  physical  condition  of  the  patient  such  that  he  cannot  withstand 
a  long  confinement  to  bed,  or  in  consequence  of  which  the  extremity,  if 
spared,  would  be  useless  :  or  (2)  in  extensive  inflammation  or  disease  of  the 
extremity  which  would  render  it  completely  incapable  of  performing  its 
functions,  or  which  threatens  the  life  of  the  patient.  Under  the  latter  head- 
ing come  extensive  gangrene,  malignant  new  growths,  irreparable  injuries 

119 


120         AMPUTATIONS,  DISARTICULATIONS,  AND  RESECTIONS. 

to  bones  and  joints,  large  ulcers,  spreading  (septic)  intermuscular  suppura- 
tion with  threatening  systemic  infection,  etc.  Under  the  separate  injuries 
and  diseases  we  shall  refer  again  to  the  indications  for  amputation  and  dis- 
articulation.    At  j)resent  the  general  suggestions  just  made  will  be  sutTicient. 

When  an  amputatio7i  and  wlien  a  disarticulation  should  be  per- 
formed are  questions  which  in  general  depend  upon  the  nature  of  the 
case  in  hand  and  the  location  of  the  injury  or  disease.  AVe  shall  dis- 
cuss this  more  fully  in  the  Regional  Surgery.  Formerly,  in  the  pre- 
antiseptic  days,  disarticulation  was  performed  more  frequently,  as  it 
dispensed  with  the  dreaded  opening  of  the  medullary  cavity.  In  fact, 
there  were  surgeons  who  went  so  far  as  to  give  up  amputations  for 
this  reason  and  performed  only  disarticulations.  Since  the  introduc- 
tion of  the  aseptic  method  of  operating  this  consideration  is  no  longer 
thought  of.  At  present  the  question  whether  amputation  or  disarticu- 
lation is  better  for  any  particular  case  is  usually  decided  by  practical 
considerations.  Both  forms  of  operation  are  practised,  and  amputation 
or  disarticulation  is  decided  upon  according  to  the  circumstances  in  each 
individual  case.  In  general,  amputations  are  performed  much  more 
frequently  than  disarticulations,  because  the  former  can  be  carried  out 
at  any  part  of  the  extremity,  while  the  latter  are  confined  to  the  joints. 

The  method  of  dividing  the  soft  parts,  particularly  the  skin,  is  prac- 
tically the  same  in  both  operations.  The  soft  parts  must  be  divided  in 
such  a  way  as  to  form  a  good  covering  for  the  bone  stump.  AVe  dis- 
tinguish three  principal  forms  of  incision — (1)  the  circular,  (2)  the  flap, 
and  (3)  the  racket-shaped  incision. 

§  36.  General  Considerations  in  regard  to  Amputations. — The  field  of 
operation  is  carefully  cleaned  throughout  its  whole  extent  with  soap 
and  a  brush,  shaved,  and  then  disinfected  with  a  three-  to  five-per- 
cent, solution  of  carbolic  acid  or  1  to  1,000  bichloride.  The  patient  is 
placed  in  a  convenient  position,  and  a  particular  duty  is  assigned  to 
each  assistant.  The  operator  stands  so  that  the  limb  to  be  operated 
upon  will  fall  to  his  right.  "We  operate  in  all  cases,  if  possible,  with 
the  assistance  of  Esmarch's  artificial  ischsemia,  described  in  §  19.  Dur- 
ing the  operation  all  the  rules  of  antisepsis  must  be  strictly  observed 
by  the  operator  and  his  assistants  ;  no  unclean  finger  or  instrument 
should  come  in  contact  wdth  the  wound.  The  knife  as  well  as  the  saw 
should  be  used  carefully  and  gently,  and  care  should  be  taken  not  to 
bear  down  too  hard  on  the  instruments.  Yiolent  manipulation  and 
compression  of  the  soft  parts  are  to  be  avoided,  as  well  as  too  vigorous 
rubbing  of  the  wound  with  sponges  or  compresses.  In  fact,  sponging 
can  be  almost  entirely  dispensed  with  when  Esmarch's  artificial  ischse- 
mia is  used. 


,36.]    GENERAL  CONSIDERATIONS  IN  REGARD  TO  AMPUTATIONS.    121 


11 

m 


I.  Circular  Division  of  the  Soft  Parts  by  a  Single  Stroke  (Celsus, 

Louis). — The  soft  parts,  having  been  drawn  up  bj  the  hands  of  an 

assistant,  are  divided  circularly  down  to  the 

bone  by  a  single  stroke  of   the  amputation 

knife  (Fig.  112)  held  at  right  angles  to  the 

axis  of  the  limb  (Fig.  113).     The  size  of  the 

amputating   knife   should   depend   upon   the 

diameter  of  the  limb.     The  knife  is  grasped 

in  the  closed  fist,  the  hand  passed  under  the 

limb,  and  the  incision  is  begun  with  the  part 

of  the  edge  nearest  the  handle,  which  is  placed 

on   that  portion  of  the  surface  of  the  limb 

which   faces   the   operator    (Fig.    113).     The 

blade  is  then  drawn  around  the  entire  circum- 
ference of  the  limb,  dividing  all  the  soft  parts 

down  to  the  bone.     I  think  it  is  easier  and 

better  to  begin  the  incision  with  the  knife  in 

the  right-angled  position,  point  upwards,  on 

the  side  of  the  limb  which  faces  away  from 

the  operator.     The  knife  is  then  carried  with 

a  sawing  motion  around  about  two  thirds  of 

the  circumference  of  the  limb,  dividing  all  the 

soft  parts  down  to  the  bone.     Starting  from 

the  beginning  of  this  incision,  the  knife  is  car- 
ried in  the  reverse  direction,  dividing  the  soft 

parts  on  the  side  of  the  limb  facing  the  operator.     After  division  of 

the  soft  parts  the  bone  is  sawed  through.     Then  the  cylinder  of  the 

soft  parts  is  drawn  up 
on  the  bone  stump  by 
an  assistant,  while  the 
operator  grasps  the  ex- 
tremity of  the  bone 
stump  with  Luer's  or 
Langenbeck's  bone 
forceps  (Figs.  83,-  dy 
and  85),  and  elevates 
or  pushes  back  the 
periosteum  by  means 
of  a  periosteal  elevator 
(raspatory,  Fig.  79)  a 

distance  equal  to  about  half  the  diameter  of  the  limb.     At  this  point 

the  bone  is  again  sawed  through,  thus  allowing  the  cylinder  of  soft 


Fig.  112. — Amputation  knives. 


Cncular  method. 


122        AMPUTATIONS,  DISARTICULATIONS,  AND  RESECTIONS, 


parts  to  completely  cover  the  stump  of  bone  and  the  edges  of  the  skin 
to  be  united,  usually  in  a  transverse  line,  without  tension  on  the 
sutures.  This  separation  of  the  periosteum  is  really  unnecessary,  and 
I  regard  it  as  a  useless  complication  of  the  operation.  It  is  simpler  to 
dissect  off  the  muscle  from  the  bone  on  all  sides,  or  to  cut 
out  a  cone  in  the  muscles  before  sawing  through  the  Ijone. 
In  amputations  of  extremities  containing  two  bones,  such  as 
the  leg,  the  forearm,  the  metacarpus  and  metatarsus,  the  mus- 
cles and  soft  parts  lying  between  the  bones  must  be  divided 
before  sawing  the  bones.  For  this  purpose  a  small,  pointed, 
double-edged  knife,  sometimes  called  a  catline,  is  best  (Fig. 
114).  This  knife  is  inserted  in  the  space  between  the  bones 
and  the  soft  parts  are  divided  by  cutting  first  with  one  edge 
against  one  of  the  bones  and  then  with  the  other  edge  against 
the  other  bone.  This  procedure  is  then  repeated  by  inserting 
the  knife  from  the  opposite  side  into  the  space  between  the 
bones.     Instead  of  the  two-edged  knife,  a  small  scalpel  can 

fbe  used  for  this  purpose.     After  dividing  the  soft  parts  in 
the  sj)ace  between  the  bones  and  laying  the  bones  free,  the 
Catline."     latter  are  sawed  in  such  a  way  that  the  division  of  both  is 
completed  at  the  same  time.     Thus,  in  amputations  of  tlie 
leg  the  tibia  is  first  sawed  about  three  quarters  through  before  one 
begins  to  saw  the  fibula,  and  then  both  are  completely  sawed  through 
at  the  same  time. 

For  sawing  the  bones  in  amputations  it  is  best  to  use  the  bow  saw 
(see  page  88,  Fig.  86,  J,  c)  in  the  way  illustrated  in  Fig.  115 — i.  e.,  the 
saw  is  placed  close  to 
the  soft  parts,  at  right 
angles  to  the  thumb  of 
the  left  hand,  which 
is  placed  upon  them. 
To  prevent  injury  to 
the  soft  parts  they  are 
retracted  by  a  split 
aseptic  compress  (Fig. 
116)  or  the  hand  of 

an  assistant.  The  distal  portion  of  the  limb  is  held  by  an  assistant,  and 
allowed  to  drop  a  little  as  the  sawing  progresses,  so  that  the  saw  does 
not  become  jammed.  If  projecting  spicules  of  bone  remain  after  the 
sawing  is  completed  they  must  be  cut  or  smoothed  off  by  bone  shears 
or  forceps,  or  the  metacarpal  saw  or  chisel  may  be  used  for  this  pur- 
pose, as  for  removing  the  anterior  projecting  border  of  the  tibia. 


Division  of  a  bone  bv  the  saw. 


§36.]    GENERAL  CONSIDERATIONS  IN  REGARD  TO  AMPUTATIONS.    123 


Fig.  116. — Split  compresses. 


On  account  of  tlie  rapidity  with  which  it  could  be  done,  the  circu- 
lar method,  performed  with  one  sweep,  used  to  be  much  employed 
when  operations  were  carried  out  without  anaesthesia,  but  at  the  present 
time  it  is  less  often  used.     In  fact,  it  is  little  _ 

suited  for  extremities  having  powerful  mus- 
cles, for  it  provides  a  more  or  less  insufficient 
covering  of  soft  parts  and  of  skin  for  the  bone 
stump,  and  therefore  is  conducive  to  the  for- 
mation of  the  so-called  conical  stump.  But, 
on  the  other  hand,  this  method  is  a  perfectly- 
proper  one  for  performing  amputations  on 
children  and  thin  subjects,  particularly  in  the 
case  of  limbs  containing  only  one  bone. 

II.  Circular  Method  of  dividing  the  Soft 
Parts  at  Two  Different  Levels. — An  incision  is 
carried  circularly  around  the  limb  through 
the  skin  down  to  the  fascia.  The  skin  is  then  drawn  up  by  an  assistant, 
while  it  is  freed  from  the  subjacent  parts  by  carrying  a  knife,  held  at 
right  angles  to  the  axis  of  the  limb,  circularly  around  the  latter  at  the 
edge  of  the  skin,  cutting  down  to  the  fascia  (Fig.  117),  or  by  dis- 
secting the  skin  and  subcutaneous  tissue  from  the  deeper  tissues  by 

means  of  a  scalpel. 
When  the  skin  has 
been  thus  sufficient- 
ly freed  from  the 
fascia  it  is  turned 
back  in  the  form  of 
a  cuff,  the  length  of 
which  should  equal 
about  half  the  di- 
ameter of  the  limb. 
A  circular  incision 
through  all  the  soft 
parts  down  to  the 
bone  is  then  made 
close  to  the  attached  edge  of  the  cutaneous  cuff,  and  the  bone  is  then 
sawed  in  the  manner  already  described.  Here  also  it  is  a  good  plan  to 
separate  the  muscular  insertions  from  the  bone  for  a  short  distance  to 
insure  a  sufficient  covering  for  the  stump. 

Funnel-shai^ed  Method.— The  so-called  funnel-shaped  method  of  divid- 
ing the  soft  parts  (Alanson)  is  only  a  modification  of  the  method  just 
described.      The   skin    is    first   divided    circularly,   and  the   knife   is   then 


Fig.  117.— Formation  of  a  cutaneous  cuff  in  a  circular  amputa- 
tion at  two  levels. 


1-24:         AMPUTATIONS,  DISARTICULATIONS,  AND   RESECTIONS. 


applied  at  the  margin  of  tlie  retracted  skin,  liaving  its  edge  directed 
obliquely  upwards  and  at  the  same  time  towards  the  bone,  in  which  direc- 
tion it  is  carried  through 
the  muscles  down  to  the 
bone.  In  this  way  a  con- 
ical -  shaped  wound  sur- 
face is  made,  with  its  apex 
towards  the  upper  end  of 
the  bone. 


Fig.  lis. — Formation  of  two  semilunar  skin  tiaps. 


Fig.  119. — Formation  of  a  large  anterior  and  small  posterior 
skin  flap. 


III.  The  Flap  Methods. — The  flap  methods  varj  in  the  thickness, 
shape,  and  length  of  the  flaps.     At  the  present  time  flaps  are  generally 

made  to  consist  onlv  of 
skin,  or  skin  and  sub- 
cutaneous tissue,  as  it 
is  well  known  that  the 
muscles  in  the  flap  cov- 
ering the  bone  stump 
subsequently  disappear 
entirely  by  fatty  degen- 
eration. But  it  is  an  ex- 
cellent plan  to  fashion 
flaps  of  both  cutane- 
ous and  muscular  tissue 
whenever  the  skin  is  very  tliin  and  badly  nourished.  The  shape  and 
position  of  the  flaps  vary  very  much,  though  anterior  and  posterior  flaps 

are  usually  made  either 
of  equal  length,  or  a 
long  anterior  and  short 
posterior  flap  are  made, 
in  order  that  the  suture 
line  shall  come  to  lie 
more  posteriorly. 

The  incision  for  the 
cutaneous  flaps  may  be 
made  in  the  same  way 
as  in  the  circular  method 
of  amputating  in  two 
stages  just  described, 
and  then  longitudinal 
incisions  some  five  or 
six  centimetres  long  are 
made  on  the  inner  and  outer  aspect  of  the  extremity,  thus  forming 
two  cutaneous  flaps  of  equal  length,  an  anterior  and  a  posterior.     These 


Fig.  120.- 


-Anterior  overhanging  flap,  and  posterior  semi- 
circular incision. 


i  36.]    GENERAL  CONSIDERATIONS  IN  REGARD  TO  AMPUTATIONS.    125 


Fig.  121. — Formation  of  a  flap  of  skin  and  muscle  by  an 
incision  from  without  inwards. 


are  then  freed  from  the  fascia  and  turned  back.     The  muscles  are 
divided  at  the  point  where  the  cutaneous  flaps  are  turned  back,  just  as 
in  the  circular  method  of  amputating  in  two  stages.     Another  wav  is 
to  form  two  semilunar-shaped  skin  flaps,  either  in 
front  and  behind  or  laterally,  using  a  large  scalpel 
with  a  blade  convex  on  the  edge.     The  flaps  of 
skin  are  dissected  from  the  fascia  and  turned  back 
(Fig.  118). 

Another  good  plan 
is  to  make  a  long,  semi- 
lunar -  shaped  anterior 
flap  of  skin  with  a  small 
posterior  flap  (Fig.  119). 
The  former  must  be 
long  enough  to  cover 
the  entire  cut  surface  like  a  curtain.  The  overhanging  anterior  flap 
is  made  in  the  simplest  way,  by  cutting  an  anterior  semilunar-shaped 
cutaneous  flap  and  freeing  it  from  the  subjacent  parts.  The  base  of 
the  flap  should  be  equal  to  about  half  the  circumference  of  the  limb, 
and  its  length  should  equal  its  sagittal  diameter.  A  similar  but  smaller 
cutaneous  flap  is  then  cut  from  the  posterior  half 
of  the  circumference  of  the  limb  and  dissected 
from  the  fascia. 

A  very  simple  way  of  carrying  out  this  method 
of  amputation  by  a  long  anterior  flap,  after  the 
latter  has  been  cut  and  turned  back,  is  to  divide 
the  skin  on  the  posterior  portion  of  the  circum- 
ference of  the  limb  by  a  single  circular  sweep  of 
the  knife.  The  posterior  flap  is  then  dissected 
back  from  below  upwards,  as  usual,  by  strokes  of 
the  knife  held  at  right  angles  to  the  axis  of  the 
limb,  and  the  muscles  are  then  cut  circularly  by 
a  single  sweep  of  the  knife  (Fig.  120). 

Some  surgeons  prefer  to  include  the  fascia  in 
the  skin  flaps,  freeing  skin  and  fascia  together 
from  the  underlying  muscles,  as  they  believe  that 
the  skin  flaps  are  better  nourished  in  this  way  by 
the  extensive  network  of  vessels  lying  between 
the  skin  and  fascia,  particularly  if  the  portion  of 
skin  in  question  is  loosely  attached  and  thin.  I  do  not  like  these  flaps 
of  combined  skin  and  fascia,  and  agree  with  Oberst  that  the  fascia,  on 
account  of  its  poor  blood  supply,  especially  if  the  conditions  for  cir- 


FiG.  122. — Disarticulation 
of  the  middle  finger: 
1,  extensor  tendon ;  2, 
flexor  tendon  and  near 
by  the  two  ligated  dig- 
ital arteries  "  and  the 
nerves.  In  the  centre 
of  the  wound  is  seen 
the  articular  surface  of 
the  metacarpus. 


126        AMPUTATIONS,  DISARTICULATIONS,  AND  RESECTIONS. 


cnlatioii  are  unfavourable,  is  liable  to  necrose  and  so  interfere  with 
primary  union.  I  think  it  better  to  form  cutaneous  flaps  without  the 
fascia.  If  the  skin  is  not  suitable  for  making'  flaps  on  account  of  being 
too  tliin,  I  prefer  the  circular  method  of  amputation,  carrying  the  knife 
to  the  bone  in  one  sweep,  or  the  method  in  which  the  flaps  include 
both  skin  and  muscular  tissue. 

The  formation  of  flaps  consisting  of  both  skin  and  muscular  tissue 
is  not  at  present  so  much  in  vogue  as  formerly.  The  wound  surface 
is  too  large,  the  flaps  are  too  heavy,  and  the  vessels  are  usually  cut 
obliquely.  These  flaps  are  formed  either  by  cutting  from  without  in- 
wards (Fig.  121),  or  in  the  reverse  direction,  from  within  outwards, 
by  means  of  transfixion.  In  the  latter  method  a  double-edged  knife  is 
inserted  close  to  the  bone,  at  the  base  of  the  flap  to  be  formed  ;  then 
the  knife  is  carried  with  a  sawing  motion  obliquely  downwards  and 
outwards.  All  transfixion  methods  are  bad,  because  the  vessels  are 
often  wounded  or  divided  in  two  different  places.  It  was  formerly 
used  very  often,  when  operations  had  to  be  performed  rapidly  without 
anaesthesia. 

lY.  The  Oval  or  Racket  Incision  (Fig.  122). — This  is  a  compromise 
between  the  single  circular  sweep  of  the  knife  and  the  flap  method. 
It  is  chiefly  used  for  disarticulating  fingers  and  toes,  but  it  is  seldom 
made  use  of  in  amputating.     It  is  really  an  obliquely  placed  circu- 
lar amputation — i.  e.,  two  lateral  in- 
cisions are  made,  which  meet  at  a 
sharp  upward  angle  on  the  back  of 
the  limb,  and  in  a  slight  downward 
curve  on  the  front. 

The    Treatment    of    Amputation 
Wounds. — Haemorrhage  after  ampu- 
tation is  arrested  by  seizing  sepa- 
rately all  the  divided  vessels,  both 
arteries  and  veins,  in  the  bloodless 
stump  with  self -locking  haemostatic 
clamps  and  then  ligating  them  with 
catgut   or   aseptic    silk   (Fig.    123). 
To  find  the  small  muscular  branches 
in  the  surface  of  the  bloodless  stump, 
one  should  follow  the  muscular  in- 
terspaces, where  the  vessels  can  be 
discovered  and  grasped  with  clamps.     If  any  vessel  cannot  be  drawn 
out  or  isolated,  it  should  be  secured  by  passing  a  sharply  curved  needle 
carrying  a  catgut  suture  through  the  soft  parts  around  the  bleeding 


Fig.  123. — Ligation  of  the  vessels  in  an 
amputation  slump. 


§  36.]    GENERAL  CONSIDERATIONS  IN  REGARD  TO  AMPUTATIONS,    127 

vessel  (page  98,  Fig.  95).  The  suture  is  then  tied  so  as  to  include  the 
soft  parts  and  the  vessel.  Small  vessels  can  be  closed  bj  torsion,  as 
described  in  §  28.  After  all  the  vessels  in  sight  have  been  ligated,  the 
Esmarch  elastic  tourniquet  is  removed,  while  the  amputation  wound  is 
elevated  and  pressure  exerted  upon  it  by  aseptic  sponges.  Pressure 
lasting  a  couple  of  minutes  is  the  best  means  of  arresting  the  ensuing 
parenchymatous  haemorrhage,  which  is  very  apt  to  be  considerable  im- 
mediately after  the  removal  of  the  Esmarch  tourniquet,  on  account  of 
the  vasomotor  paralysis  that  it  causes. 

When  the  haemorrhage  has  been  very  carefully  arrested  the  large 
nerve  trunks  are  drawn  out  of  the  wound  and  cut  off  with  scissors,  to 
prevent  the  possibility  of  any  subsequent  neuralgia  or  the  formation  of 
amputation  neuromata.  After  this  the  wound  is  disinfected,  together 
with  the  parts  surrounding  it,  by  irrigation  with  a  1  to  1,000-5,000 
bichloride  solution,  or  a  three-per-cent.  solution  of  carbolic  acid,  suit- 
ably drained,  and  its  margins  are  united  by  sutures.  If  the  asepsis  has 
been  perfect  throughout,  there  is  no  necessity  of  antiseptic  irrigation 
of  the  wound,  as  this  only  causes  irritation  and  increases  the  subse- 
quent discharge  from  the  wound.  It  is  sufficient  to  wash  out  the 
wound  with  a  sterilised  seven-tenths-per-cent.  solution  of  common  salt 
or  simple  warm  boiled  water.  The  drainage  tubes  are  fastened  to  the 
skin  by  a  suture,  one  tube  being  generally  placed  in  the  posterior  flap, 
and,  when  necessary,  others  are  placed  in  the  angle  of  the  wound  at 
each  side  (§  31).  The  wound  is  closed  (§  33)  by  inserting  several  in- 
terrupted tension  sutures  and  then  a  continuous  catgut  suture.  Great 
care  must  be  taken  in  inserting  the  sutures.  They  should  be  even, 
and  hold  the  margin  of  the  wound  in  perfect  apposition.  All  drawing 
and  tension  must  be  avoided,  l^euber  recommends  the  use  of  several 
rows  of  sutures  for  closing  an  amputation  wound.  He  sutures  first  the 
periosteum,  then  the  muscles,  and  finally  the  skin,  and  thus  avoids  the 
formation  of  any  pockets.  According  to  my  ideas,  this  form  of  sutur- 
ing is  unnecessary  and  even  bad,  and  I  have  found  that  an  aseptic 
dressing,  applied  so  as  to  exert  suitable  pressure,  is  entirely  sufficient 
to  prevent  the  formation  of  pockets.  Crede  dispenses  with  both  drain- 
age and  suturing  in  amputation  wounds,  and  obtains  primary  union 
simply  by  compression  of  the  wound  with  the  dressings.  I  have  tried 
this  method  and  found  it  very  satisfactory. 

An  aseptic  protective  covering  which  exerts  moderate  pressure  is 
the  most  suitable  form  of  dressing  for  amputations.  The  stump,  after 
application  of  the  dressing,  is  placed  in  a  slightly  elevated  position, 
and  left  for  the  time  being  uncovered,  so  that  any  secondary  haemor- 
rhage may  be  recognised  at  once. 


128        AMPUTATIOXS,  DISARTICULATIONS,  AND  RESECTIONS. 

Subperiosteal  Amputations.— Oilier,  particularly,  has  upheld  subperiosteal 
amputations,  reasoning  from  tlie  results  obtained  fi-om  experiments  made  on 
animals.  He  makes  a  flap  from  the  periosteum  to  promote  primary  union 
of  the  deeply  lying  parts,  and  to  prevent  inilammatory  complications  from 
occurring  in  the  medullary  cavity.  But  when  this  method  is  used  on  man 
the  results  are  not  so  good  as  the  experiments  on  animals  would  seem  to 
indicate.  At  present  Oilier  has  himself  given  up  periosteal  flaps,  and  even 
considei-s  them  harmful  in  children,  on  account  of  the  tendency  to  form 
osteophytes.  Bruns  has  recently  recommended  the  employment  of  the  sub- 
periosteal method  for  amputation  of  the  leg.  It  possesses  the  advantage  here 
of  preventing  gangrene  of  the  flaps.  Subperiosteal  disarticulations  can  be 
highly  recommended  (see  Disai'ticulations).  In  order  to  obtain  a  stump  that 
would  support  better  the  weight  of  the  body  Bier  used  to  make  an  artificial 
foot  by  turning  up  the  end  of  the  tibia  (see  Regional  Surgery),  and  for  the 
same  purpose  he  now  covers  the  wound  surface  with  a  pedunculated  peri- 
osteum bone  flap  from  the  tibia  (see  Regional  Surgery).  The  stump  of  the 
tibia  may  also  be  covered  with  a  flap  from  the  fibula  (Lanz). 

Amputation,  with  Scraping  Out  of  the  Diseased  Medullary  Cavity.— In 
diseases  of  the  marrow  of  bone,  such  as  suppurative  osteom^'elitis,  Ivonig 
and  Stoll  have  performed  amputation  accompanied  by  scraping  out  the 
marrow,  and  have  obtained  good  results.  In  this  way  disarticulation  at  the 
joint  above  can  be  avoided. 

§  3".  The  Method  of  performing  Disarticulations. — The  technique 
is  in  the  main  the  same  as  for  amputations.  The  method  by  circular 
incisions  at  two  levels,  with  turning  back  of  a  cutaneous  cuff,  can  be 
used,  or  flaps  may  be  cut  of  skin,  or  skin  and  muscular  tissue  combined. 

In  disarticulations,  a  long  anterior  overhanging  flap  and  a  small 
posterior  one  are  much  used,  and  are  made  as  described  above  (Figs. 
119,  121).  In  disarticulations  at  the  ankle  or  medio-tarsal  joint,  or 
of  the  fingers  or  toes,  the  posterior  flap  can  be  make  the  larger.  For 
disarticulation  at  the  small  joints  of  the  fingers  or  toes,  especially  the 
metatarso-  and  metacarpo-phalangeal  joints,  the  racket  incision  is  very 
often  used  (Fig.  122). 

After  dividing  the  overlying  soft  parts  in  the  form  of  skin  flaps,  or 
flaps  of  skin  and  muscular  tissue  combined,  or  after  making  the  circular 
incision  in  two  stages  and  turning  back  the  cutaneous  cufl^,  the  ligaments 
of  the  joint  are  made  tense  and  the  joint  opened.  Whenever  it  is  neces- 
sary, any  prominent  part  entering  into  the  formation  of  the  joint  can  be 
cut  away ;  and  it  is  sometimes  best  to  extirpate  the  synovial  membrane 
completely,  in  order  to  obtain  a  wound  surface  to  which  the  cutaneous 
flaps  may  unite  more  rapidly.  The  details  for  performing  disarticula- 
tions are,  in  general,  precisely  similar  to  those  for  amputations. 

For  the  method  of  performing  disarticulation  on  particular  joints, 
as  well  as  the  various  amputations,  the  reader  is  referred  to  the  text- 
book on  Regional  Surgery. 


§38.]  AFTER-TREATMENT   OF   AMPUTATIONS.  129 

Subperiosteal  Disarticulation.— Oilier,  especially,  has  recommended  the 
reg-ular  use  of  subpei-iosteal  disarticulation.  Ollier's  description  is  as  fol- 
lows :  The  same  incision  is  made  as  for  resection  of  the  particular  joint 
in  question  (see  §  40),  dividing  at  the  same  time  both  capsule  and  perios- 
teum. By  means  of  a  raspatory  the  periosteum  is  elevated  from  the  bone 
and  pushed  aside  from  the  joint,  together  with  such  muscular  insertions 
as  are  present ;  the  head  of  the  bone  is  then  enucleated,  and  the  soft  parts 
cut  transversely  to  the  axis  of  the  limb.  Extensive  new  formation  of  bone 
has  been  observed  after  subperiosteal  disarticulation,  not  only  in  animals, 
but  also  in  man  in  early  life.  This  is  especially  true  of  subperiosteal  dis- 
articulation and  amputation  through  the  upper  end  of  the  metatarsus  or 
metacarpus,  and  also  after  disarticulation  at  the  tibio-tarsal  joint  with 
preservation  of  the  periosteum  of  the  os  calcis.  New  bone  has  been  seen 
to  develop  within  the  hip  joint  after  subperiosteal  disarticulation  of  the 
head  of  the  femur.  This  new  bone  was  movable  within  the  joint  and  gave 
support  to  the  stump.  The  subperiosteal  and  subcapsular  shelling  out  of 
the  bone  is  probably  of  most  use  in  cases  of  disarticulation  for  gunshot 
injuries. 

History. — During  the  middle  ages  and  until  the  close  of  the  sixteenth 
-century  amputations  were  done  in  the  most  horrible  ways,  on  account  of  the 
inefficient  methods  then  in  vogue  for  arresting  hsemorrhage,  and  usually 
ended  fatally.  The  bleeding  was  checked  by  encircling  the  member  to  be 
operated  upon  with  a  strong  rope,  or  the  red-hot  iron  was  used ;  boiling  oil 
was  poured  over  the  wound,  or  the  operation  was  performed  with  red-hot 
knives.  Permanent  constriction  of  the  limb  and  caustics  were  also  some- 
times used.  The  technique  was  very  greatly  advanced  by  the  introduction 
of  the  ligature  of  vessels  by  Ambrose  Pare  and  his  followers  (1659-1692),  and 
after  this  by  the  invention  of  the  tourniquet  by  Morel  (1674).  The  ligature 
of  vessels  for  arresting  hgemorrhage  had  been  well  understood  by  the  sur- 
geons of  antiquity,  and  was  in  general  use  in  the  time  of  the  Roman  Empire. 
The  ligature  was  afterwards  entirely  forgotten,  as  has  been  mentioned,  and 
was  later  rediscovered  by  Pare. 

In  more  recent  times  amputation  was  occasionally  performed  by  the 
ecraseur  (Chassaignac),  the  galvano-cautery  (Bruns),  and  the  elastic  ligature 
(Dittel).  But  now  all  these  methods  have  become  simply  matters  of  history 
since  the  introduction  of  antiseptics. 

§  38.  The  After-treatment  of  Amputations  and  Disarticulations. — The 

after-treatment  of  amputations  and  disarticulations  is  very  simple  if  no 
fever  occurs  and  the  wound  runs  a  normal  course  in  healing.  The 
:first  dressing  should  not  be  disturbed  till  the  time  arrives  for  removing 
the  drains — i.  e.,  till  the  second,  third,  or  fourth  day,  according  to  the 
size  of  the  wound.  Some  of  the  stitches  are  also  taken  out  at  the  same 
time.  Then  the  second  dressing  is  applied,  and  it  is  often  the  last.  If 
fever  occurs,  or  if  the  patient  complains  of  pain,  the  dressing  should 
be  changed  earlier. 

For  the  details  of  treating  the  patient  who  has  been  operated  upon, 
reference  is  made  to  §  22. 
10 


130        AMPUTATIONS,  DISARTICULATIONS,  AND  RESECTIONS. 

Bad  Results.— Since  the  introduction  of  the  present  antiseptic  method 
of  operating  and  treating  wounds  the  immediate  bad  results  which  have 
been  observed  to  follow  amputations  and  disarticulations  are  infrequent. 
It  is  generally  expected  that  healing  will  take  place  without  any  reac- 
tion. The  occurrence  of  wound  infection — such  as  suppuration,  pyae- 
mia, septicaemia,  erysipelas,  and  osteomyelitis,  so  frequently  observed  in 
the  preantiseptic  period — is  now  exceptional,  and  only  takes  place  when 
an  extremity  is  operated  upon  which  is  ah'eady  infected,  or  when  the 
rules  of  asepsis  are  not  rigidly  adhered  to.  For  the  treatment  of  these 
diseases  of  wounds  resulting  from  infection,  as  well  as  for  the  treatment 
of  shock,  delirium  tremens,  etc.,  reference  is  made  to  §  62  to  §  75. 

Among  the  other  immediate  bad  symptoms  after  amputation  we 
may  mention  the  occurrence  of  cramps  or  violent  contractions  of  the 
muscles  in  the  stump.  These  are  liable  to  come  on  soon  after  the 
operation,  and  are  best  treated  by  subcutaneous  injections  of  morphine 
and  by  fixation  of  the  stump  by  means  of  light  sand-bags,  etc.  (See 
also  §  64,  Delirium  Tremens.) 

Secondary  haemorrhage  also  occurs  much  less  frequently  than  it 
formerly  did,  because  we  have  learned  to  take  great  pains  to  arrest  all 
bleeding  during  the  operation.  Secondary  heemoi-rhage  starts  either 
from  an  unsecured  vessel  which  had  retracted  at  the  time  that  the 
bleeding  from  the  stump  was  being  stopped,  or  from  a  vessel  which 
had  been  tied  ofi  but  had  opened  again.  In  such  cases  of  secondary 
haemorrhage  from  an  artery  often  nothing  but  the  reopening  of  the 
wound  and  the  securing  of  the  bleeding  vessel  will  suffice  to  check  it. 
The  best  way  of  treating  parenchymatous  secondary  haemorrhage  or 
oozing  is  to  apply  an  aseptic  dressing  in  such  a  manner  as  to  exert 
proper  pressure  and  to  place  the  stump  in  an  elevated  position.  At  a 
later  stage  in  the  process  of  healing  it  is  still  possible  for  secondary 
haemorrhage  to  occur  from  perforation  of  the  wall  of  the  vessel  result- 
ing from  suppuration  when  the  wound  does  not  heal  by  primary 
union.  The  treatment  of  this  is  also  practically  the  same — i.  e.,  the 
haemorrhage  should  be  stopped  by  applying  a  ligature  at  the  point 
from  which  blood  issues. 

If  the  skin  is  very  thin,  or  if  the  skin  flaps  lie  upon  a  non-vascular 
surface  like  cartilage,  as  is  the  case  in  disarticulations,  or  if  the  dress- 
ings are  applied  so  as  to  exert  too  much  pressure,  there  is  apt  to  be  a 
more  or  less  extensive  death  or  gangrene  of  the  flaps.  In  such  cases 
one  must  either  await  the  separation  of  the  damaged  portion  of  the 
flap,  or,  if  the  gangrene  is  too  extensive,  a  higher  amputation  must  be 
performed.  The  gangrene  is  sometimes  due  to  constitutional  causes 
(diabetes,  arteriosclerosis,  etc.). 


§38.]  AFTER-TREATMENT   OF  AMPUTATIONS.  131 

Sometimes  necrosis  occurs  in  the  stump  of  the  bone,  especially  if 
there  has  been  suppuration.  Under  these  circumstances  one  must  wait 
until  the  sequestrum  has  become  loosened,  and  then  remove  it.  The 
bone  stump  does  not  necrose  if  the  wound  heals  normally  and  without 
reaction. 

Another  bad  result  after  amputation  is  the  so-called  conical  stump. 
This  may  be  the  fault  of  the  method  of  operating — i.  e.,  the  cutaneous 
flaps  were  made  too  short  for  sufficiently  covering  the  bone  stump,  or 
it  may  be  due  to  the  death  of  part  of  the  cutaneous  flaps,  or  to  retrac- 
tion of  the  soft  parts  as  a  result  of  suppuration.  This  latter  cause  was 
relatively  common  in  the  preantiseptic  period  of  surgery.  At  present 
conical  amputation  stumps  are  rare,  and  are  usually  the  result  of  an 
unskilful  performance  of  the  operation.  In  rare  cases  a  conical  stump, 
particularly  after  amputation  of  the  upper  arm  and  the  leg,  may  occur 
in  young  individuals  from  longitudinal  growth  of  the  bone  at  the  upper 
intact  epiphysis.  Poncet  observed  in  one  case  a  growth  of  eight  centi- 
metres in  three  years.  In  a  well-marked  conical  stump  the  end  of  the 
bone  projects  from  the  soft  parts  through  the  granulating  surface  of 
the  wound,  and  either  cicatrisation  does  not  take  place,  or  the  slowly 
forming,  adherent  scar  is  so  tense  and  sensitive  that  the  use  of  the 
stump  and  the  wearing  of  an  artificial  limb  are  impossible.  Under  such 
conditions  there  is  nothing  to  be  done  but  to  perform  a  reamputation 
or  a  subperiosteal  resection  of  the  bone.  The  latter  is  best  carried  out 
by  making  a  longitudinal  incision  through  the  soft  parts  and  periosteum 
down  to  the  stump  of  bone,  care  being  taken  to  avoid  large  vessels 
and  nerves ;  the  periosteum  and  the  overlying  soft  parts  are  then 
separated  by  means  of  the  raspatory  and  periosteal  elevator  from  the 
bone,  and  a  sufficiently  long  piece  of  bone  is  removed  with  the  saw  or 
hammer  and  chisel. 

Since  the  era  of  aseptic  surgery,  the  neuralgia  of  the  amputation 
stump  which  used  to  occur  after  suppuration  is  seldom  observed.  The 
pain  is  caused  in  some  cases  by  cicatricial  contraction  following  sup- 
puration and  resulting  in  constriction  of  the  ends  of  the  nerves,  and  in 
other  cases  the  enlarged  ends  of  the  nerves  become  adherent  to  the 
bone  or  the  superficial  layer  of  the  stump.  The  ends  of  the  nerves 
usually  show  a  club-shaped  enlargement  (amputation  neuroma).  The 
latter  consists  of  connective  tissue  with  more  or  less  numerous  bundles 
of  newly  formed  nerve  fibres.  The  formation  of  these  amputation 
neuromata,  which  sometimes  cause  very  severe  pain,  is  best  prevented 
by  aseptic  healing  and  by  drawing  out  the  ends  of  the  large  nerves 
with  forceps  after  every  amputation  and  cutting  off  a  considerable 
portion  with  scissors,  in  order  that  the  nerves  may  retract  well  between 


132         AMPUTATIONS,  DISARTICULATIONS,  AND  RESECTIONS. 

the  muscles.  Moreover,  great  care  should  be  taken  not  to  include 
nerves  in  the  ligatures  placed  on  the  vessels.  The  treatment  of  neu- 
ralgia occurring  in  a  stump  consists  in  the  excision  of  a  long  piece 
of  the  alfected  nerve  trunk  (neurectomy),  and  in  the  extirpation  of  any 
neuromata  which  may  be  present. 

During  the  first  few  days  or  weeks  many  patients  who  have  under- 
gone an  amputation  complain  of  pain  of  greater  or  less  severity 
referred  to  the  amputated  part,  which,  however,  gradually  disappears 
in  the  great  majority  of  cases.  On  account  of  irritation  of  the  ends 
of  the  sensory  nerve  fibres  which  originally  supplied  the  fingers  or  toes, 
these  patients  feel  pain  in  those  parts  though  they  no  longer  possess 
them.  The  sensations  referred  to  the  portions  of  the  extremities 
which  no  longer  exist  last  a  variable  length  of  time — often  a  year — and 
patients  are  very  likely  to  dream  that  they  still  have  their  lost  limb. 

Death  following  Amputation  and  Disarticulation. — A  fatal  result  fol- 
lowing amputation  or  disarticulation  is  either  caused  by  one  of  the 
forms  of  wound  infection,  such  as  septicaemia,  pysemia,  erysipelas,  or 
tetanus,  or  by  collapse,  by  anaemia  from  great  loss  of  blood,  by  second- 
ary haemorrhage,  delirium  tremens,  fat  emboli,  or  other  intercurrent 
diseases.  In  general,  age  does  not  play  so  important  a  part  in  the 
prognosis  of  amputations  and  disarticulations  as  it  formerly  did,  be- 
cause we  have  learned  how  to  avoid  loss  of  blood,  and  healing  is  more 
rapid  with  the  aseptic  method  of  operating.  It  often  happens  in  old 
people  that  there  is  marked  atheromatous  degeneration  of  the  arteries, 
and  yet  the  wound  will  heal  satisfactorily.  Furthermore,  syphilis, 
tubercuJosis,  and  kidney  disease  have  no  such  deleterious  effect  on 
healing  as  was  formerly  believed.  In  every  case  the  prognosis  after 
an  amputation  is  favourable  if  there  are  no  complications,  and  if  there 
has  been  no  transgression  of  the  rules  of  antisepsis. 

Mortality  of  Amputations. — The  mortality  of  aseptic  amputations  varies 
with  the  nature  of  the  case  and  the  presence  or  absence  of  complications. 
According  to  Oberst,  of  260  uncomplicated  amputations  14  died,  a  mortality 
of  5.4  per  cent. ;  but,  on  the  other  hand,  there  were  39  deaths  in  91  cases 
where  complications  were  present,  a  mortality  of  42.8  per  cent.  Of  57  am- 
putations in  which  sepsis  was  already  present,  40  recovered,  and,  taking-  all 
cases  without  distinction,  Oberst  collected  351  amputations  with  53  deaths,  or 
a  mortality  of  15.1  per  cent.,  and  84.9  per  cent,  recoveries.  Wolfier  has  given 
the  total  mortality  of  amputations  occurring  in  Billroth 's  clinic  as  19.7  per 
cent.  In  uncomplicated  cases  the  mortality  was  5.7  per  cent.,  and  in  those  in 
which  complications  occurred — i.  e.,  in  amputations  where  sepsis  and  pyaemia 
were  already  present — the  mortality  was  43.7  per  cent.  Essen  (in  Wahl's 
clinic)  gives  the  total  death  rate  as  17.9  per  cent.,  the  mortality  of  uncompli- 
cated cases  being  5.93  per  cent.,  and  of  those  with  complications  42.8  per  cent. 
The  mortality  of  the  255  amputations  performed  in  Czerny's  clinic  was  only 


§39.] 


ARTIFICIAL  LIMBS. 


133 


2.7  percent.  (Schrade).  The  decrease  in  the  mortality  is  to  be  asci'ibed  solely 
to  the  aseptic  method  of  treating  wounds,  and  the  mortality  of  amputations 
and  disarticulations  would  be  still  less  if  all  the  operations  coiild  be  per- 
formed immediately  after  the  injury. 

§  39.  Artificial  Limbs. — The  substitution  of  artificial  limbs  for  lost 
extremities  has  become  more  and  more  common  in  recent  years.  In 
tbe  case  of  the  lower  extremity,  the  prothetic  apparatus  need  only  ren- 
der standing  and  walking  possible,  and  consequently  it  is  conceivable 
that  more  satisfactory  results  can  be  obtained  here  than  in  the  upper 
extremity,  where  the  manifold  movements  of  the  hand  and  fingers  can 
be  only  partially  supplied ;  and  not  every  one  is  in  a  position  to  pro- 


FiG.  124.— Artificial  limbs  for  the  upper  extremity:  a,  for  the  forearm;  J,  for  the  upper  arm; 
0,  d,  and  e,  limbs  with  different  kinds  of  insertion  pieces. 

vide  himself  with  such  costly  apparatus  as  artificial  arms  and  legs,  with 
their  complicated  mechanism.  As  to  the  upper  extremity,  the  move- 
ments of  the  fingers  are  usually  imitated  by  spiral  springs,  or  springs 
are  placed  in  the  apparatus  in  such  a  way  as  to  make  the  latter  mova- 
ble when  manipulated  by  the  other  hand  or  pressed  against  the  thorax 
by  the  stump,  etc.  The  simplest  and  cheapest  prothetic  apparatus  for 
an  amputated  arm  or  forearm  consists  of  a  leather  socket  in  which  the 
stump  is  placed  and  retained  by  straps.  The  artificial  hand  should  be 
arranged  so  that  it  can  be  taken  off  and  replaced  by  a  hook,  a  knife,  or 
a  claw  (Fig.  124,  c,  d,  e).  It  is  remarkable  how  much  some  patients 
can  sometimes  accomplish  with  such  a  simple  apparatus. 


134         AMPUTATIONS,  DISARTICULATIONS,  AND  RESECTIONS. 

After  ainputatiun  or  disarticulation  of  the  lower  extremity  we  make 
use  either  of  the  peg  leg  (Figs.  125  to  127) 'or  the  artificial  limb  (Figs. 
128,  129).  The  peg  leg  is  the  cheaper  and  by  far  the  simpler  appa- 
ratus, and  with  it  walking  is  generally  easier  and  nioi'e  comfortable 
than  with  the  artificial  limb.  Many  who  have  long  been  tormented 
by  the  latter  turn  finally  to  the  use  of  the  peg.  And  it  is  worth  taking 
into  consideration  that  the  peg  leg  can  be  repaired  by  any  mechanic, 
while  the  artificial  limb  recjuires  a  skilled  instrument-maker.  Trende- 
lenburg and  others  have  shown  that  the  peg  leg  can  be  improvised 
very  cheaply  by  fastening  a  stick  of  wood  to  a  socket  made  of  paste- 


FiG.  125.— Peg  Fig.  126.— Peg  Fig.  127.— Peg  leg  Fig.  128.— Arti- 

leg  for  ampu-  leg  for  arapu-  for  amputations          ficial  foot, 

tations  below  tations  at  the  of  the  thigh, 

the  knee.  knee. 


Fig.  129.— Artificial  leg 
for  disarticulations  at 
the  hip,  or  high  am- 
putation of  the  thigh. 


board  by  means  of  a  water-glass  bandage.  The  artificial  leg  is  usually 
made  of  a  leather  pocket  in  which  the  stump  is  placed  ;  to  this  is  joined 
the  leg,  which  is  made  of  wood,  having  hinges  for  the  knee  and  ankle 
joints.  The  foot  can  be  extended,  when  pressing  against  the  ground, 
by  means  of  a  strong  spiral  spring.  The  movement  of  the  knee  joint 
is  accomphshed  by  some  elastic  material  placed  inside  the  leg  and 
simulating  the  function  of  the  muscles.  If  only  a  part  of  the  foot  is 
lost  the  defect  can  be  concealed  and  walking  rendered  possible  by  pad- 
ding an  ordinary  boot  with  cotton.  Some  artificial  legs  are  made  with 
a  rubber  foot. 


§40.]  OPERATIONS  ON  JOINTS.  135 

These  brief  remarks  will  suffice  for  a  general  understanding  of  the 
principles  of  artificial  limbs. 

Crutches. — Crutches  must  be  well  padded,  as  otherwise  they  may  give  rise 
to  so-called  crutch  paralysis  from  pressure  on  the  nerves  in  the  axilla. 

§  40.  Operations  on  Joints. — Bj  resection  of  a  joint  is  meant  the 
partial  or  complete  operative  removal  of  the  opposed  bony  surfaces 
forming  the  joint  by  means  of  the  saw,  sharp  spoon,  or  chisel.  A  dis- 
tinction is  made  between  partial  and  complete  resection,  depending 
upon  whether  the  ends  of  the  bone  are  completely  or  only  in  part 
removed.  If  the  joint  is  extensively  diseased,  we  do  not  satisfy  our- 
selves with  removal  of  the  bony  portion,  but  also  extirpate  the  synovial 
membrane — i.  e.,  we  perform  a  complete  extirpation  of  the  joint.  In 
all  cases  in  which  the  periosteum  is  healthy  we  preserve  it  on  account 
of  its  osteoplastic  power,  and  call  a  resection  of  this  kind  subperiosteal. 
A  distinction  is  made  between  early  and  late  resection  and  between 
primary,  intermediate,  and  secondary  resection.  By  primary  resection 
is  meant  one  which  is  performed  immediately  after  the  traumatism  has 
occurred  and  before  the  onset  of  inflammatory  reaction.  The  inter- 
mediate resection  is  performed  after  inflammatory  symptoms  appear. 
A  secondary  resection  is  one  performed  after  the  subsidence  of  the 
inflammatory  reaction,  when  the  wound  is  granulating. 

Resection  of  Bones  in  Continuity. — Furthermore,  we  resect  bones  in 
their  continuity  when  we  remove  greater  or  less  amounts  of  diseased 
portions  of  them  by  means  of  the  chisel  or  saw.  The  removal  of  dis- 
eased bone  by  the  sharp  spoon — for  example,  in  tuberculosis — is  desig- 
nated as  a  scraping  out,  while  the  simple  division  of  bone  in  its  con- 
tinuity is  called  osteotomy. 

Arthrectomy. — If  the  bony  parts  forming  the  joint  are  left  intact, 
and  only  the  diseased  synovial  membrane  of  the  joint  is  removed,  as  in 
tuberculosis,  the  operation  is  an  arthrectomy.  The  simple  opening  of 
the  joint  is  called  arthrotomy.  We  shall  confine  ourselves  here  to  the 
general  technique  of .  joint  resections,  and  shall  take  up  the  resections 
of  particular  joints  in  the  Regional  Surgery. 

Indications  for  Resection  of  a  Joint. — The  indications  for  resecting  a 
joint,  especially  for  performing  total  resection,  have  become  much  fewer  in 
number  since  the  introduction  of  antiseptic  surgery.  At  the  present  time  we 
are  often  able  to  save  a  joint— one,  for  instance,  which  has  been  laid  open 
by  a  wound — where  formerly  it  would  have  been  sacrificed.  We  now  go  on 
the  principle  of  performing  a  resection  as  conservatively  as  possible — i.  e., 
we  try  to  preserve  as  much  of  the  articular  surfaces  of  the  bone  as  we  can. 
The  complete  resection  of  joints  in  children,  which  used  to  be  so  frequently 
performed  for  tuberculosis,  should  be  entirely  given  up.     In  these  cases  we 


136         AMPUTATIONS,  DISARTICULATIONS,  AND  RESECTIONS. 

should  be  satisfied  with  removing  the  diseased  portion  of  the  bone  with  the 
sharp  spoon  or  the  cliisel.  with  the  single  exception  of  the  hip  joint ;  and  in 
adults  the  use  of  total  I'esection  should  be  restricted  as  much  as  possible,  and 
as  much  bone  saved  as  possible.  If  only  the  capsule  of  the  joint  is  diseased 
— as,  for  example,  in  tuberculosis — only  this  should  be  extirpated  (arthrec- 
tomy),  and  the  bony  portion  of  the  joint  should  be  left  intact.  When 
arthrectomy  is  performed— for  instance,  at  the  knee  in  the  case  of  synovial 
disease — a  movable  joint  may  be  obtained  (Augerer,  Sendler,  myself,  and 
others).  On  the  other  hand,  it  cannot  be  denied  that  a  verj-  good  functional 
result  is  possible  after  an  extensive  atypical  i'esection,  as  in  the  case  of  the 
foot,  and  amputation  be  thus  avoided.  I  agree  with  Kappeler,  Mikulicz, 
Kiister,  and  others  in  sanctioning  extensive  atypical  resections,  particularly 
of  the  foot. 

In  general,  resection  of  a  joint  is  indicated  after  severe  injuries  (trau- 
matic resection)  and  for  pathological  changes  in  the  joint  (pathological 
resection).  Among  conditions  in  a  joint  calling  for  resection  are  (1)  com- 
pound fractures  involving  the  joint,  with  considerable  splintering  of  the 
bones,  especially  gunshot  fractures ;  also  dislocations  accompaiiied  by  rup- 
ture of  the  skin  and  overlying  parts.  Since  the  introduction  of  antisepsis  it 
will  often  be  found  sufficient  in  these  cases  to  drain  the  joint  thoroughly 
after  reducing  the  dislocation  or  removing  whatever  loose  fragments  are  en- 
tirely detached.  Resection  of  a  joint  is  also  called  for  (2)  when  there  is  very 
extensive  suppuration  or  violent  inflammation  in  the  joint  after  an  injury, 
and  especially  when  there  is  (3)  chronic  disease  of  the  joint,  tuberculosis 
being  the  most  common.  Resections  may  also  be  performed  for  (4)  loss  of 
function  in  a  joint  caused  by  contractures  or  anchylosis,  and  in  old  disloca- 
tions in  which  there  is  a  malposition  of  the  bones  which  interferes  with  the 
function  of  the  joint,  or  in  which  the  head  of  the  bone  presses  on  nerves 
and  vessels,  and,  finally,  (5)  for  new  growths  in  the  bones. 

Osteoclasis,  or  subcutaneous  fracture  of  bones  by  the  osteoclast  (Mol- 
liere),  has  of  late  years  been  used  very  largely  in  place  of  the  so-called  ortho- 
paedic resections  for  improving  deformities  of  bone.  But  I  agree  with  Oilier, 
that  osteoclasis  is  not  always  as  effective  as  its  inventor  claims ;  and,  fur- 
thermore, it  is  not  always  possible  to  break  the  bones  at  precisely'  the  desired 
point  and  without  damaging  the  soft  parts.  Osteoclasis  cannot  usually  be 
employed  in  cases  of  anchylosis. 

General  Rules  for  performing  Resection. — The  operation  of  resecting- 
a  joint  is  divided  into  three  stages  :  (1)  The  incision  through  the  soft 
parts  ;  (2)  opening  the  joint ;  (3)  division  and  removal  of  the  injured 
or  diseased  ends  of  the  bones  witli  or  without  extirpation  of  tlie  syno- 
vial menabrane.  AYhen  possible,  the  operation  sliould  be  performed 
with  the  aid  of  Esmarch's  artificial  ischaBmia,  and  of  course  with  the 
strictest  aseptic  precautions.  The  soft  parts  are  divided  Avith  a  short, 
strong  knife  (Fig.  130).  Resection  knives  are  sometimes  pointed, 
sometimes  rounded,  or  blunt.  The  incision  through  the  soft  parts  is 
made  preferably  in  the  long  axis  of  the  limb,  because  this  involves  the 
least  injury  to  nmscles  and  tendons  at  their  point  of  insertion,  as  well 


§40.] 


OPERATIONS   ON  JOINTS. 


isr- 


Fig.  130. — Eesection  knives. 


as  to  vessels  and  nerves.  Only  in  the  case  of  the  knee — and,  under 
certain  conditions,  the  ankle — are  transverse  incisions  allowable  for 
affording  a  better  view  of  the  diseased  joint.  The  joint  is  opened  in 
the  line  of  the  cutaneous  incision.  It  is  very  important  for  the  future 
function  of  the  joint  to  preserve  the  tendinous  insertions  of  the  mus- 
cles about  the  joint  and  to  keep  intact  their  connection,  as  well  as  that 
of  the  capsule  with  the  periosteum. 
In  all  cases  where  the  periosteum  is 
healthy,  as  in  primary  traumatic  re- 
sections, it  should  be  preserved — 
i.  e.,  a  subperiosteal  resection  should 
be  performed.  If  it  is  diseased,  it 
must  of  course  be  removed,  as  well 
as  the  bone.  If  the  periosteum  is 
to  be  retained — that  is,  if  -^-e  are 
going  to  do  a  subperiosteal  resec- 
tion— it  is  divided  in  the  line  of  the 
cutaneous  incision  and  raised  by  the 
raspatory  (Fig.  79)  and  periosteal 
elevator  (Fig.  80).  At  those  places 
where  the  periosteum  becomes  con- 
tinuous with  the  capsule,  muscular  insertions,  and  ligaments,  it  must 
be  separated  from  the  bone  by  perpendicular  or  horizontal  strokes  of 
the  knife. 

Yogt  and  Konig  have  introduced  an  excellent  plan  for  retaining 
the  connection  of  the  muscular  insertions  to  the  bony  protuberances  to 
which  they  are  attached.  These  protuberances  are  separated  from  the 
shaft  of  the  bone  by  the  hammer  and  chisel,  or,  in  the  case  of  children, 
by  the  knife,  and  at  the  conclusion  of  the  operation  they  are  again 
brought  back  into  place  and  secured  by  means  of  silver  wire  or  nails. 
When  there  is  a  tubercular  arthritis  involving  the  whole  joint,  or  when 
diseased,  it  would  of  course  be  a  mistake  to  preserve  the  periosteum. 
In  such  cases  the  joint  must  be  entirely  extirpated— i.  e.,  all  diseased 
soft  parts  and  bone  must  be  removed. 

The  periosteum  having  been  removed,  or  left  in  place,  as  the  case 
may  be,  the  next  step  is  the  division  of  the  bone  (see  §  26).  The  ends 
of  the  bone  are  forced  out  of  the  wound,  while  the  soft  parts  are  held 
aside  by  retractors,  or  the  bony  parts  are  divided  in  situ  with  the  meta- 
carpal, bow,  or  chain  saw,  or  with  the  chisel.  The  bones  of  children 
can  be  cut  with  the  knife.  After  division  of  the  bone  all  projecting 
angles  are  levelled  off. 

If  anchylosis  is  desired— for  example,  in  the  case  of  the  knee— the 


138         AMPUTATIONS,  DISARTICULATIONS,  AND   RESECTIONS. 

ends  of  the  boues  are  fastened  together  with  catgut,  silver  wire,  or 
four-cornered  steel  nails  which  liave  been  carefully  disinfected  (see 
also  §  34).  Since  partial  resections  give  in  general  a  better  func- 
tional result  than  total  ones,  the  former  should  be  given,  when  possible, 
the  preference  in  all  joints  in  which  we  wish  to  obtain  motion.  The 
strictest  asepsis  must  be  maintained  in  all  stages  of  the  operation.  At 
its  conclusion  the  haemorrhage  must  be  arrested  witli  the  utmost  care, 
drainage  of  the  joint  must  be  provided  for,  and,  after  suturing  the 
wound  and  applying  an  antiseptic  dressing,  the  joint  must  be  immo- 
bilised by  a  suitable  splint.  If  an  Esmarch  tourniquet  is  used,  it  can 
either  be  removed  before  inserting  the  sutures  and  the  haemorrhage 
stopped,  or  one  can  suture  the  wound,  leaving  the  two  angles  open, 
apply  an  aseptic  dressing,  and  then  remove  the  tourniquet.  I  then 
apply  a  plaster-of- Paris  splint  over  the  aseptic  dressing,  and  this  is  kept 
on  for  about  four  weeks.  In  order  to  diminish  the  secondary  bleed- 
ing the  extremity  is  elevated  or  suspended.  In  case  of  extensive  sup- 
puration of  the  joint,  it  must  be  thoroughly  drained  by  tubes  or  gauze. 

For  the  method  of  dressing  individual  joints  after  resection,  refer- 
ence is  made  to  the  text-book  on  Regional  Surgery. 

Outcome  of  Resections  of  Joints. — The  results  of  joint  resections  are 
either  anchylosis,  or  an  actively  movable  joint,  or  a  so-called  flail-like 
joint.  In  the  lower  extremity,  at  the  knee  and  ankle,  anchylosis  is  the 
most  desirable  result.  In  the  hip  and  upper  extremity  a  movable  joint 
is  preferable.  For  restoring  the  function  of  a  joint  after  the  wound 
has  healed,  the  after-treatment  is  of  great  importance.  It  is  possible 
to  obtain  very  excellent  results  by  the  methodical  use  of  active  and 
passive  motion,  by  electricity,  massage,  and  baths.  If  anchylosis  is 
desired,  the  joint  should  be  immobilised  in  the  position  which  is  most 
suitable  for  subsequent  use,  by  means  of  a  plaster  dressing  or  a  splint 
left  in  place  for  a  considerable  length  of  time  (see  Methods  of  Dress- 
ing, and  Regional  Surgery).  If  a  flail-like  joint  is  obtained,  it  must 
be  re-enforced  by  a  suitable  supporting  apparatus,  or  another  operation 
must  be  done  to  obtain  anchylosis  (see  Arthrodesis,  below). 

The  causes  of  death  ioWow-ing  resection  are,  in  the  flrst  place,  the 
infectious  wound  diseases,  such  as  sepsis  or  pyaemia,  due  to  imperfect 
asepsis,  or  to  their  presence  at  the  time  of  the  operation.  Furthermore, 
death  may  result  from  exhaustion  due  to  the  long  confinement  in  bed, 
or  from  the  underlying  general  disease,  usually  tuberculosis.  Patients 
w^ho  have  undergone  this  operation  sometimes  die  from  fat  emboli, 
especially  when  there  is  advanced  fatty  degeneration  of  the  bone  mar- 
row. Bones  in  which  there  is  this  fatty  degeneration  should  not  be 
joined  together  too  closely. 


§40.]  OPERATIONS   ON  JOINTS.  I39 

History  of  Resections. — Eesections  were  performed  in  the  flourishing  days 
of  surgery  at  the  time  of  the  Roman  Empire,  but  were  forgotten  entirely 
during  the  middle  ages,  and  were  not  again  systematically  practised  till  near 
the  close  of  the  eighteenth  century.  In  England,  White  was  the  first  to  use 
the  operation,  performing  a  resection  of  the  humerus.  In  France  the  oper- 
ation was  employed  by  Moreau  ;  later,  by  Sabatier,  Percy,  Dupuytren,  and 
Larry.  Textor,  Jager,  and  Ried  introduced  the  operation  among  German 
surgeons.  Langenbeck  has  done  more  than  anybody  to  advance  the  tech- 
nique of  joint  resection. 

Arthrodesis. — By  arthrodesis  is  understood  the  artificial  anchylosis  of  a 
flail-like  joint — in  cases  of  paralysis,  for  example,  for  which  it  was  first  prac- 
tised by  Albert,  who  operated  with  excellent  results  on  both  knee  joints  of 
a  young  girl  suffering  from  paralysis  of  the  lower  extremities.  The  opera- 
tion is  very  useful,  especially  for  paralytic  flail-like  joints.  At  first  arthro- 
desis was  frequently  performed  by  fastening  the  bones  together  with  a  wire 
suture  after  a  typical  resection  of  their  joint  surfaces.  But  it  is  a  better 
plan  to  merely  scrape  off  the  articular  surfaces,  leaving  some  of  the  cartilage 
behind,  and  then  unite  the  bones  with  long,  perfectly  sterilised  steel  nails 
instead  of  the  silver- wire  suture.  The  synovial  membrane  should  be  allowed 
to  remain  intact.  If  healing  takes  place  with  some  slight  amount  of  sup- 
puration, the  synostosis  of  the  joint  ends  of  the  bones  is  more  solid  than  if 
the  wound  unites  by  primary  union  (Zinsmeister).  H.  Euringer  has  col- 
lected from  literature  68  cases  of  arthrodesis  (in  50  patients),  of  which  the 
majority  were  successful,  and  enabled  the  patients  to  dispense  with  the 
heavy,  uncomfortable,  and  expensive  splint  apparatus.  Karasiewicz  collected 
87  cases  (in  61  patients),  of  which  44  were  performed  on  the  ankle,  33  on  the 
knee,  and  the  others  on  the  shoulder,  elbow,  hip,  Chopart's,  and  the  calcaneo- 
astragaloid  joints.  The  results  were  good  (bony  union)  in  59  cases,  satisfac- 
tory (fibrous  union)  in  25,  and  bad  in  3. 

Arthrolysis. — Arthrolysis,  or  anchylolysis,  is  the  opposite  of  arthrodesis. 
It  consists  in  open  division  of  all  bands  and  adhesions  both  inside  ajid  out- 
side the  joint  which  interfere  with  its  movement.  The  joint  surfaces  are 
not  resected,  and  in  this  way  an  anchylosed  or  contracted  joint  may  become 
movable  again. 


CHAPTEE  X. 

OPEEATIONS    FOE    EEl^CEDTING    DEFECTS    IN    THE    TISSUES. PLASTIC 

OPEEATIONS. — TEANSPLANTATION. 

Plastic  operations  for  loss  of  substance  in  the  skin. — General  methods  of  plastic  sur- 
gery in  case  of  loss  of  substance  in  the  skin:  movability  of  skin;  liberating 
incisions;  formation  of  flaps  with  pedicles;  implantation  of  entirely  separated 
portions  of  skin. — Skin-grafting  by  the  methods  of  Krause,  Reverdin.  and  Thiersch. 
— Grafts  of  skin  or  mucous  membrane  taken  from  animals. — Ilair-grafting. — 
Plastic  operations  for  defects  in  other  tissues  (muscles,  tendons,  nerves,  bones). 

§  41.  Plastic  Operations  for  Cutaneous  Defects. — If  the  loss  of  sub- 
stance in  the  tissues  is  so  great  that  it  cannot  be  remedied  by  simply 
suturing  together  the  borders  of  the  wound,  we  perform  what  has 
been  called  by  the  general  name  of  a  plastic  operation,  for  remedying 
the  defect  or  bringing  about  a  more  rapid  cicatrisation. 

We  shall  first  take  up  the  operative  treatment  of  loss  of  substance 
in  the  skin.  These  defects  are  either  fresh  and.  the  result  of  an  injury 
or  an  operation,  or  they  are  old  or  congenital,  or  made  up  of  a  granu- 
lating wound  surface.  For  treatino-  such  defects  in  the  skin,  or  for 
hastening  cicatrisation,  there  are  in  general  two  princijDal  methods : 

1.  The  closure  of  the  defect  by  traction  upon  the  skin  in  the  neigh- 
bourhood, or  by  the  formation  of  a  cutaneous  flap,  which  is  freed 
from  the  underlying  parts  in  such  a  way  that  it  still  possesses  a  bridge 
of  skin  at  some  portion  of  its  circumference,  called  a  pedicle,  connect- 
ing it  with  the  neighbouring  skin. 

2.  The  defect  is  also  remedied  hj  the  transplantation  or  implanta- 
tion of  an  entirely  detached  portion  of  skin.  The  first  method,  in. 
which  the  defect  is  remedied  by  traction  on  the  surrounding  skin  and 
by  the  formation  of  a  movable  flap  with  a  pedicle,  is  what  is  ordinarily 
meant  by  a  plastic  operation. 

Defects  not  only  in  the  skin,  but  also  in  muscles,  tendons,  nerves, 
and  bone,  can  be  remedied  by  plastic  operations — i.  e.,  by  the  forma- 
tion of  flaps  with  pedicles  or  by  the  transplantation  of  portions  of  tissue 
entirely  separated  from  their  original  surroundings.  Modern  aseptic 
surgery  has  made  great  advances  in  plastic  operations  and  in  the 
grafting  of  different  tissues  on  others. 
140 


§41.]  PLASTIC   OPERATIONS   FOR   CUTANEOUS  DEFECTS.  141 

The  cutaneous  defects  in  which  plastic  operations  are  called  for  are 
caused  by  injuries  and  by  diseases  of  every  description  (wounds  from 
freezing  or  burning,  inflammation  causing  necrosis,  operations  for  tu- 
mours, malformations  like  harelip,  ectopia  vesicas,  etc.).  Plastic  opera- 
tions are  also  indicated  in  cicatrices  causing  deformity  or  loss  of  func- 
tion in  a  part.  The  ancient  surgeons,  particularly  in  India,  were  skilled 
in  this  branch,  having  plenty  of  opportunity  for  performing  rhinoplasty 
and  otoplasty,  on  account  of  the  frequency  of  the  form  of  punishment 
which  consisted  in  cutting  off  the  nose  or  ears. 

If  small  portions  of  the  body,  like  the  tips  of  the  fingers  or  the 
nose,  are  completely  cut  off,  they  will  sometimes  reunite  in  their 
proper  position  by  primary  union  if  they  are  carefully  sutured  in  place 
with  every  antiseptic  precaution,  provided  the  piece  of  tissue  is  not  too 
large  and  not  too  much  crushed,  and  the  sutures  are  applied  immedi- 
ately after  the  receipt  of  the  injury.  "We  shall  return  to  the  subject 
of  the  reuniting  of  small,  completely  severed  portions  of  tissue  in  the 
chapters  on  Injuries  and  the  Repair  of  Wounds. 

General  Principles  of  Plastic  Surgery. — The  following  is  a  brief  state- 
ment of  the  general  principles  governing  plastic  surgery,  the  details 
of  which  for  special  plastic  operations — such  as  rhinoplasty,  cheilo- 
plasty,  the  operations  for  ectopia  vesicas,  etc. — will  be  considered  in 
the  text-book  on  Regional  Surgery. 

It  is  of  the  greatest  importance  for  the  success  of  any  plastic  opera- 
tion, or  for  the  union  of  a  skin  flap  in  its  new  bed,  that  the  operation 
should  be  conducted  with  the  strictest  attention  to  asepsis.  The  bor- 
ders of  the  wound  should  be  as  smooth  and  sharply  outlined  as  possible, 
the  flaps  should  be  cut  of  adequate  size,  not  too  small  or  too  thin,  and 
the  subcutaneous  fatty  tissue  should  be  preserved  in  its  connection  with 
the  flap.  The  sutures  should  be  of  catgut  or  fine  aseptic  silk,  and 
should  be  so  applied  that  the  borders  of  the  wound  are  held  in  exact 
apposition. 

Coaptation  of  the  Borders  of  the  Wound  and  Freeing  of  the  Skin 
from  Underlying  Parts.— The  simplest  way  of  closing  a  defect  in  the 
skin  consists  in  drawing  together  the  borders  of  the  wound  and  uniting 
them  with  sutures.  To  render  the  edges  of  skin  more  movable,  they 
can  be  dissected  free,  together  with  the  attached  subcutaneous  fat,  from 
the  underlying  parts.  Thus  cutaneous  defects  of  the  most  diverse 
shapes,  if  not  too  large,  may  be  easily  closed,  as  illustrated  in  Fig.  131. 
Julius  Wolff  has  recently  elaborated  this  method  of  closing  defects  by 
drawing  over  them  the  adjoining  skin,  which  has  first  been  freed  from 
the  subjacent  parts,  and  then  suturing  the  edges  of  the  skin.  He  has 
in  this  way  closed  large  areas  where  loss  of  substance  has  occurred  in 


142    OPERATIONS   FOR  REMEDYING   DEFECTS   IN  TUE   TISSUES. 

skin  and   in  bone,  and  lias  also  applied  it  to  widely  opened  joints. 
The  skin  is  loosened  for  some  distance  around  the  wound,  partly  with 


MIllH  ^ 


Fig.  131. — Union  of  the  borders  of  an  area  where  there  has  been  a  loss  of  substance  in  the  skin  ; 
the  edges  of  the  sliin  are  freed  from  the  underlying  parts  and  united  by  sutures :  a,  before 
inserting  the  sutures ;  b,  after  inserting  the  sutures. 

the  hand  and  partly  with  a  blunt-pointed  knife  or  scissors,  and  then 
brought  over  the  wound  and  sutured  (Berlin,  klin.  Wochenschr.,  1890, 

:n'o.  6). 

In  other  cases  it  is  best  to  make  use  of  lateral  liberating  incisions ; 
i.  e.,  before  or  after  inserting  the  sutures  in  the  approximated  margins 
of  the  wound,  an  incision  is  made  parallel  to  and  at  one  side  of  the 
suture  line,  in  order  to  lessen  the  tension  on  the  suture  line  (Fig.  132,  a). 

As  illustrated  in  Fig.  132,  b,  the  lib- 
erating incisions  cause  slightly  gap- 
ing wounds  after  the  defect  has  been 
closed,  but  these  usually  heal  rapidly 
by  aseptic  granulation. 

In  a  third  category  of  cases  the 
skin  is  drawn  over  a  defect  after  mak- 
ing one  or  more  incisions  prolonged 
from  the  limit  of  the  original  defect 
in  any  required  direction,  and  by  this 
means  forming  a  kind  of  Hap.  This  is  only  a  modification  of  the 
method  of  closing  a  defect  by  sliding  the  skin  over  it,  and  does  not 
belong  to  the  impof'tant  method  of  plastic  surgery  about  to  be  de- 

vr  n  T I  n  T" 


Fig.  132. — Lateral  liberating  incisions :  a, 
before  inserting  the  sutui'es ;  b,  after 
inserting  the  sutures. 


Fig.  1&3. — Incision  prolonged  from  one  corner  of  a  triangular  wound  :  a,  before,  and  A,  after, 

inserting  the  sutures.  " 


scribed — namely,  the  formation  of  a  flap  with  a  pedicle.  In  Figs.  133, 
13-1,  and  135  are  seen  examples  of  the  application  of  this  method.  In 
Fig.  133  the  original  incision  has  been  prolonged  in  the  line  c  d,  and 


§41.] 


PLASTIC   OPERATIONS   FOR   CUTANEOUS  DEFECTS. 


143 


the  portion  of  skin  a  c  d  is  tlins  rendered  capable  of  being  moved, 
c  being  drawn  over  to  h,  and  the  two  borders  of  the  defect  are  united 
with  sutures,  giving  the  result  illustrated  in  Fig.  133,  h.  In  the  same 
manner,  under  other  circumstances,  a  second  incision  can  be  prolonged 
from  the  original  defect  at  b.  When  the  three-cornered  defect  is  closed 
by  sutures  there  results  some  slight  puckering  of  the  skin  at  the  sides. 
Burow  remedies  this  by  excising  small  three-cornered  portions  of  skin 


lyi n  ru 


Fig.  134. — Curved  incision  from  one  corner  of  a  triangular  Tvound :  a,  before,  and  J,  after,  insert- 
ing the  sutures. 

in  this  region.  This  plan  of  excising  a  triangular-shaped  portion  of 
tissue,  which  Burow  introduced,  is  at  present  but  little  used.  In  Fig. 
134  the  liberating  incision  cd\&  prolonged  from  the  edge  of  the  defect 
in  a  curved  direction,  and  here  also  a  second  curved  incision  from  h 
can  be  employed  with  advantage  for  closing  the  defect  by  sliding  over 
it  a  portion  of  the  adjoining  skin.     In  Fig.  135  four  lateral  incisions 


"WWUWW 


11 1 1  n  i  1  u- 


Fig.  135.— Prolonged  incisions  for  uniting  a  four-cornered  wound  :  a,  before,  and  5,  after,  insert- 
ing the  sutures. 


are  made  for  closing  a  quadrilateral  defect.  This  principle  of  making 
lateral  incisions  or  prolonging  the  original  incisions,  followed  by  draw- 
ing the  skin  over  the  defect,  is  capable  of  almost  endless  variations. 

Formation  of  Flaps  with  Pedicles. — The  most  important  method  used 
in  plastic  surgery  consists  in  fashioning  flaps  which  have  a  pedicle — 
i.  e.,  cutaneous  flaps  which  remain  connected- with  their  original  locality 
in  the  skin  by  means  of  a  bridge  or  pedicle  through  which  they  are 
nourished,  hut  throughout  all  the  rest  of  their  extent  they  are  com- 
pletely separated  from  their  original  bed.  After  this  has  been  done 
the  flap  is  laid  in  the  defect,  as  illustrated  in  Fig.  136,  h.     In  Fig.  136 


144    OPERATIONS  FOR  REMEDYING  DEFECTS  IN  TUE  TISSL'ES. 

two  lateral  flaps  are  fashioned  (Fig.  136,  a)  and  placed  in  the  defect 
(Fig.  136,  i),  so  that  Fig.  136,  c,  results  when  the  edges  of  the  wound 
are  united  by  sutures.     In  Fig.  137,  a  J,  and  Fig.  138  are  illustrated 


\  A^\ 


Fig.  136. — Formation  of  two  lateral  flaps  of  skin  ;  «  and  J,  before,  c,  after,  inserting  the  sutures. 

the  method  of  performing  a  complete  rhinoplasty.  For  details  and 
other  methods  of  performing  rhinoplasty  reference  is  made  to  the 
Regional  Surgery. 

When  flaps  with  pedicles  are  used  care  must  be  taken  that  the 
blood  supply  is  good  and  that  primary  union  is  obtained.  The  pedicle 
must  be  so  situated  that  as  many  vessels  as  possible  enter  the  flap  ;  and 
the  pedicle  must  not  be  too  narrow  or  too  thin.  The  flap,  particularly 
the  portion  constituting  the  pedicle,  is  freed  with  every  precaution  for 
preventing  its  becoming  too  thin.     Moreover,  it  is  important  that  the 


Fig.  137. — Ehinoplasty  :  a,  fresheninor  of  the  borders  of  the  de- 
fect in  the  skin,  and  formation  of  the  pear-shaped  flap  on 
the  forehead ;  5,  after  placing  the  flap  over  the  defect  in 
the  skin. 


Fig.  138.  —  Langenbeck's 
method  for  performing 
rhinoplasty. 


part  representing  the  pedicle  should  not  be  subject  to  too  much  tension 
when  the  flap  is  implanted  on  the  defect,  for  otherwise  the  nutrition 
might  be  materially  impaired. 


41.] 


PLASTIC  OPERATIONS  FOR  CUTANEOUS  DEFECTS. 


145 


Plastic  surgery  performed  with  flaps  having  a  pedicle  was  the  form 
in  which  it  was  especially  used  by  Indian  surgeons,  and  they  probably 
originated  it. 

FJaps  have  also  been  fashioned  from  portions  of  the  body  widely 
separated  from  the  defect,  as  we  shall  see  when  we  take  up  rhino- 
plasty. Tagliacozzi  (Taliacotius,  1597),  a 
physician  of  Bologna  living  in  the  sixteenth 
century,  was  the  first  to  use  a  flap  fashioned 
from  the  skin  in  the  biceps  region  of  the 
arm,  and  after  placing  the  arm  over  the 
nasal  defect  and  allowing  the  flap  to  heal 
into  the  latter,  he  cut  the  flap  loose  by  divid- 
ing its  pedicle  (Fig.  139).  This  Italian 
method,  as  it  is  called,  is  only  applicable  to 
those  exceptional  cases  in  which  good  mate- 
rial for  making  the  flap  cannot  be  obtained 
in  the  neighbourhood  of  the  defect.  The 
Italian  method  is  usually  performed  in  three 
stages  :  (1)  The  formation  of  a  flap  which 
remains  attached  by  two  pedicles ;  the  flap 
is  separated  from  the  underlying  parts  after  making  two  lateral  inci- 
sions, and  its  reunion  prevented  by  iodoform  gauze  or  oiled  silk  placed 
Tinder  the  flap,     (2)  After  granulation  has  become  well  established  one 


Fig  139  — Italian  method  of  per 
forming'  rhinoplasty  (Taglia- 
cozzi and  Graefe). 


Fig.  140. — Covering  over  of  a  cutaneous 
defect  at  the  elbow  by  a  pedunculated 
flap  from  the  chest. 


Fig.  141. — Cutaneous  flap  healed  in  place. 


pedicle  is  divided,  and  the  flap  is  sutured  into  the  defect  (Fig.  139). 
(3)  After  the  flap  has  healed  into  its  new  bed,  or  after  eight,  ten,  or 
fourteen  days,  the  other  bridge  of  skin  or  pedicle  is  divided.     Graefe 
11 


140    OPERATIONS  FOR  REMEDYING  DEFECTS  IN  THE  TISSUES. 

lias  performed  the  Italian  method  in  one  sitting  by  bringing  the  flap 
directly  in  contact  with  the  defect  (the  German  method).  But  the 
nutrition  of  the  fresh  flap  is  often  poor,  and  it  is  likewise  very  apt 
to  shrink. 

The  transplantation  of  pedunculated  flaps  from  other  parts  of  the 
body  has  of  late  come  more  into  use  in  cases  where  skin-grafting  is  not 
possible.  By  this  method  a  conservative  treatment  of  severe  injuries 
on  the  extremities  can  be  carried  out  in  many  cases  where  it  used  to 
be  impossible.  Pedunculated  flaps  from  the  chest,  for  example,  have 
been  transplanted  upon  fresh  or  granulating  defects  in  the  upper  arm 
or  forearm  (see  Figs.  140  and  141),  and  have  thus  prevented  or  over- 
come contractures  of  the  elbow  joint  after  burns,  avulsion  of  the 
skin,  etc. 

Granulating  Skin  Flaps. — Isot  only  fresh  but  also  granulating  skin 
flaps  are  used,  as  we  have  seen,  esjDCcially  for  closing  congenital  defects 
in  the  bladder  (ectopia  vesicae).  (See  Regional  Surgery.)  For  closing 
a  defect  in  the  wall  of  a  cavity,  as  in  ectopia  vesicae,  and  defects  in  the 
cavity  of  the  mouth  following,  for  example,  the  removal  of  a  cancer, 
Blessing  has  recommended  the  use  of  flaps  covered  with  epidermis. 
After  fashioning  a  skin  flap  with  a  pedicle,  its  wound  surface  is  pro- 
vided with  epidermis  by  skin-grafting  (see  page  147),  and  then  the  flap 
is  allowed  to  heal  into  the  defect. 

Skin  Flaps  with  a  Pedicle  of  Subcutaneous  Tissue — Gersuny's  Method. 
— Gersuny  was  the  first  to  show  that  a  skin  flap  which  possessed  only 
a  pedicle  of  subcutaneous  tissue  would  receive  sufiicient  nourishment 
to  enable  it  to  be  used  for  plastic  purposes,  particularly  in  remedying 
defects  of  mucous  membrane.  The  flap  is  simply  turned  into  the  de- 
fect like  a  door  on  its  hinges,  or  it  is  drawn  into  a  more  deeply  lying 
region  through  a  suitably  placed  slit  or  wide  button -hole. 

§  42.  Skin-grafting. — The  transplantation  of  skin  for  hastening  the 
skinning  over  of  granulating  surfaces  was  first  employed  by  the  Indian 
surgeons,  and  was  brought  into  use  again  by  Reverdin  in  1870.  A 
granulating  wound  in  which  the  corium  is  entirely  absent  can  only  be- 
come covered  with  skin  by  gradual  ingrowth  of  the  latter  from  the 
edges.  It  is  only  possible  for  skin  to  start  to  grow  outward  from  the 
middle  of  a  granulating  surface  when  there  still  remains  in  this  area 
remnants  of  the  rete  Malpighii  or  of  the  sebaceous  glands.  By  skin- 
transplantation  not  only  is  the  length  of  time  required  for  a  wound  to 
skin  over  shortened,  but  the  subsequent  cicatricial  contraction  is  con- 
siderably dirninished.  Pieces  of  skin  containing  the  whole  thickness  of 
the  cutis  will  very  seldom  heal  in  place,  and  consequently  they  should 
consist  only  of  epidermis  and  a  part  of  the  cutis.     Krause's  method  is 


§  42.]  SKIN-GRAFTING.  I47 

a  good  one.  A  strip  of  skin  (as  mncli  as  twenty  to  twenty-five 
centimetres  in  length  and  six  to  eight  centimetres  in  width)  is  taken 
from  the  thigh,  for  example,  and  the  defect  thus  made  closed  by 
a  continuous  suture.  The  subcutaneous  fat  is  then  removed  from 
the  strip  of  skin,  and  the  latter  cut  into  two,  three,  or  more  pieces. 
These  pieces  of  skin  are  then  placed  on  the  wound  surface  and  made 
to  adhere  by  slight  pressure.  The  factor  of  chief  importance  in 
this  method  of  skin-transplantation  is  the  strictest  asepsis,  a  dry 
method  of  operating,  and  careful  preparation  of  the  wound  surface 
to  be  covered.  ]^either  the  transplanted  skin  nor  the  wound  surface 
should  be  treated  with  antiseptics,  lest  the  integrity  of  the  cells  be 
damaged. 

Thiersch's  Method  of  Skin-grafting. — Thiersch's  method  is  the  one 
most  frequently  employed.  In  the  case  of  fresh  defects  the  skin  is 
applied  after  the  bleeding  has  been  completely  arrested,  but  in  granu- 
lating wounds  the  layer  of  granulation  is  first  removed  with  a  knife  or 
sharp  spoon.  It  is  possible,  however,  to  graft  skin  on  to  a  granulating 
surface,  especially  granulating  bone.  Moreover,  skin  can  be  grafted 
from  a  fresh  cadaver  before  the  onset  of  rigor  mortis,  or  from  a  limb 
which  has  just  been  amputated.  Epidermis  cells  remain  alive  for  a 
surprisingly  long  time  outside  the  body  if  they  are  kept  moist  in  ster- 
ile salt  solution  or  in  sterile  ascitic  fluid.  Ljungren  kept  pieces  of 
skin  from  two  days  to  more  than  three  months  in  sterile  ascitic  fluid, 
and  used  them  successfully  for  grafting.  The  microscopic  examina- 
tion showed  that  the  epithelium  had  really  multiplied  by  karyokinesis. 
Wentscher  and  Enderlen  made  similar  observations.  Wentscher  kept 
some  pieces  of  skin  in  sterile  salt  solution,  and  others  dry  in  a  closed 
bottle.  In  his  experiments  the  freshest  skin  that  was  grafted  success- 
fully was  seven  days  old,  and  the  oldest  twenty-two  days. 

Thiersch's  method  of  skin-grafting  is  as  follows  :  The  instruments 
to  be  used  are  sterilised  by  boiling  them  for  about  five  minutes  in  a 
one-per-cent.  soda  solution  and  are  then  placed  in  a  sterilised  six-tenths- 
per-cent.  solution  of  common  salt.  Antiseptic  solutions  hke  bichloride 
of  mercury  and  carbolic  acid  should  not  be  used,  as  they  endanger  the 
vitality  of  the  cells  in  the  pieces  of  skin  to  be  transplanted.  The  lat- 
ter are  taken  preferably  from  the  arm  or  the  lower  extremity,  etc. 
The  area  of  skin  in  question  is  thoroughly  washed  with  sterilised  soap 
and  warm  water  and  shaved.  As  large  a  razor  as  possible,  or  a  micro- 
tome, is  covered  with  sterilised  oil,  and  while  the  skin  to  be  cut  is  put 
on  the  stretch,  as  thin  flaps  as  possible  are  shaved  off  from  it.  To 
secure  rapid  healing,  the  pieces  of  skin  should  be  laid  upon  a  wound 
from  which  the  blood  has  been  removed  as  completely  as  possible 


148    OPERATIONS  FOR  REMEDYING   DEFECTS  IN  THE   TISSUES. 

(Garre).  I  mentioned  above  tLat  it  is  not  necessary,  as  Tliierscli  first 
taught,  to  remove  tlie  granulations,  because  it  is  jDerfectly  possible  to 
graft  upon  a  granulating  surface  that  has  been  thoroughly  cleansed. 
The  very  thinnest  graft  contains,  besides  the  entire  thickness  of  the 
papillary  layer,  a  part  of  the  underlying  stroma.  In  this  way  pieces 
of  skin  ten  to  twelve  centimetres  long  and  two  centimetres  broad  can 
be  made  to  heal  into  their  new  position.  The  larger  grafts  are  carried 
upon  an  especially  broad  spatula  and  then  spread  out  over  the  wound 
with  a  probe.  Great  care  should  be  taken  that  the  edges  of  the  piece 
of  skin  do  not  roll  up,  and  the  separate  pieces  should  be  placed  next 
one  another  with  their  edges  just  touching.  This  method  is  particu- 
larly valuable  for  fresh  cutaneous  defects  caused  by  operations  or 
injuries,  for  burns  in  the  stage  of  granulation,  for  ulcers  of  the  leg, 
for  broad  and  deep  granulating  areas  following  operations  for  necrosis, 
etc.  After  removing  a  large,  soft  fibroma,  I  successfully  covered  with 
epidermis  almost  the  entire  hairy  portion  of  the  scalp  in  one  sitting  by 
Thiersch's  method  of  skin-grafting ;  I  also  made  a  large  permanent 
opening  into  the  left  pleural  cavity  for  empyema  and  tuberculosis,  and 
changed  it  into  a  gutter  by  use  of  the  same  method  (see  Regional  Sur- 
gery, §  126).  In  short,  the  method  is  an  excellent  one.  Thiersch  has 
also  transplanted  the  skin  of  a  negro  upon  a  white  man  and  the  skin 
of  a  white  man  upon  a  negro.  The  negro's  skin  took  i-oot  on  the 
white  man  with  exceptional  rapidity,  but  the  attempt  failed  in  the 
majority  of  cases  in  which  skin  was  transplanted  from  the  white  man 
on  to  the  negro,  no  matter  whether  a  granulating  or  a  fresh  wound 
surface  was  used.  It  is  interesting  to  note  that  the  portions  of  white 
skin  implanted  on  the  negro  gradually  turned  black,  and  vice  versa. 
The  histological  investigations  of  Karg  showed  that  the  pigment  does 
not  originate  in  the  cells  of  the  rete  Malpighii,  but  is  brought  to  them 
by  the  wandering  cells  which  come  from  the  deeper-lying  portions 
of  tissue  laden  with  pigment  and  find  lodgment  among  the  cells  of 
the  rete.  Consequently  the  white  skin  implanted  on  the  negro  be- 
comes gradually  black,  and  the  negro's  skin  implanted  on  the  white 
man  becomes  white  from  ceasing  to  receive  deposits  of  pigment.  The 
pigment  particles  are  probably  identical  with  the  cell  granules  discov- 
ered by  Altmann  and  by  him  called  bioblasts,  and  are  probably  formed 
from  them  by  the  help  of  the  blood  in  some  unknown  way.  Accord- 
ing to  Jarisch,  the  pigment  of  the  negro's  skin  lies  almost  entirely  in 
the  deeper  cells  of  the  rete  Malpighii  and  is  entirely,  or  almost  en- 
tirely, absent  from  the  more  superficial  cells. 

Dressings  after  Skin-grafting. — The  dressing  for  a  skin -grafted  area 
should  be  one  which  does  not  adhere  to  its  surface,  as  the  pieces  of 


§  42.]  SKIN-GRAFTING.  I49 

skin  are  easily  torn  off  when  the  dressing  is  changed.  In  place  of  the 
wet  dressings  of  oil  or  salt  solution,  which  were  at  one  time  in  general 
use,  I  employ  dry  dressings — i.  e.,  I  sprinkle  the  grafts  with  iodoform 
or  dermatol  powder,  and  apply  rubber  tissue  with  holes  made  in  it,  or 
iodoform  gauze,  which  does  not  adhere  so  easily  as  sterile  gauze,  and 
later  I  use  dressings  of  boric  ointment.  On  the  extremity  careful 
immobilisation  is  necessary.  The  first  dressing  is  kept  on  for  from 
three  to  five  or  eight  days.  Great  care  is  necessary,  in  removing  the 
dressing,  not  to  disturb  the  grafts.  If  the  grafts  have  "  taken,"  the 
area  they  cover  presents  a  mosaic  appearance  due  to  the  separate  pieces 
of  skin  used  for  the  grafts.  Later  on  the  borders  of  the  separate 
pieces  of  skin  become  less  and  less  marked,  and  occasionally  become 
quite  indistinguishable.  The  epidermis  generally  comes  off,  and  is 
liable  to  give  the  erroneous  impression  that  the  grafting  has  failed. 
Success  is  easily  prevented  by  suppuration  or  bleeding.  E.  Fischer 
has  made  the  interesting  observation  that  those  skin -grafts  become 
attached  the  easiest  which  are  taken  from  and  transplanted  upon  parts 
which  have  previously  been  rendered  ansemic  by  the  use  of  Esmarch's 
rubber  bandage. 

The  Histological  Changes  in  Skin-grafting  are  in  general  the  same  as  in 
primary  union  of  a  wound.  The  transplanted  piece  of  skin  is  at  first  passive, 
but  from  the  third  day  on  it  becomes  supplied  with  blood  by  vascular 
sprouts  from  the  wound.  In  spite  of  this  interruption  for  two  days  in  the 
circulation,  most  of  the  tissue  elements  of  the  graft  remain  alive  ;  only  the 
horny  layer,  a  portion  of  the  rete  Malpighii,  and  most  of  the  vessels  die. 
From  the  third  to  the  fourth  day  on  the  graft  takes  an  active  part  in  healing 
in  place ;  the  epithelial  cells,  including  those  belonging  to  the  divided  hair 
follicles  and  gland  ducts,  send  out  proliferations  of  cells  into  the  underlying 
exudate.  In  about  fourteen  days  the  granulation  tissue  is  replaced  by  con- 
nective tissue.  The  subepithelial  layer  arising  from  the  granulation  tissue 
formed  from  the  wound  surface  is  the  real  cicatrix.  Complete  union  of  the 
transplanted  skin  on  to  its  new  bed  requires,  however,  several  weeks  and  some- 
times months,  and  we  must  wait  this  length  of  time  before  subjecting  the 
new  skin  to  external  injurious  influences,  otherwise  it  may  break  through. 
According  to  Enderlen  the  Thiersch  grafts  do  not  show  a  liberal  supply  of 
elastic  fibres  until  one  and  a  quarter  to  one  and  a  half  years  afterward. 
The  greater  part  of  Krause's  graft  (see  page  146)  dies,  and  is  gradually 
replaced  by  newly  formed  tissue,  which  corresponds  in  shape  to  the  trans- 
planted skin,  and  even  contains  newly  formed  papillee.  A  cicatrix  of  this 
sort,  on  account  of  its  firmness  and  slight  tendency  to  contraction,  is  much 
better  than  the  usual  scar. 

Wblfler's  Transplantation  of  Mucous  Membrane.— Wolfier  (see  Langen- 
beck's  Archiv,  Bd.  xxxvii)  has  successfully  transplanted  mucous  membranes 
taken  from  man  and  animals  upon  defects  in  various  mucous  membranes. 
His  method  is  to  be  greeted  as  a  new  and  valuable  advance  in  the  treatment 


150    OPERATIONS   FOR  REMEDYING    DEFECTS  IN  THE   TISSUES. 

of  defects  in  mucous  membrane,  such  as  strictui'es  and  defects  in  the  urethra, 
conjunctiva,  cheek,  etc.  Gersuny,  Witzel,  and  others  have  remedied  defects 
in  mucous  membranes  by  turning  in  flaps  of  skin  possessing  a  pedicle  of  sub- 
cutaneous tissue  only  (see  page  146). 

Implantation  of  Hair. — Schwenninger  and  Nussbaum  have  attempted  to 
implant  hair  by  strewing  it  over  a  granulating  area  where  there  has  been  a 
loss  of  skin.  If  the  root  sheath  still  remained  attached  to  the  hair,  it  became 
adherent  and  formed  a  centre  from  which  cicatrisation  proceeded,  but  the 
hair  itself  fell  out  after  a  few  days.  Hairs  without  their  root  sheath  did  not 
become  attached  at  all. 

Mangoldt's  Method  of  Skin-grafting. — Mangoldt  recommends  scraping 
the  sterilised  skin  with  a  razor,  down  to  the  papillary  layer,  and  spread- 
ing the  mixture  of  epithelial  cells  and  blood  thus  obtained  upon  a  clean 
bloodless  non-granulating  wound.  I  have  tried  this  method  and  can  recom- 
mend it. 

Transplantation  of  Skin  and  Mucous  Membrane  from  Animals  {Rah- 
bits,  Frogs). — The  skin  and  mucous  membranes  of  animals  have  also 
been  successfully  transplanted  upon  man.  The  conjunctiva  of  a  rabbit 
has  been  successfully  grafted  in  a  defect  of  the  human  eyelid.  Bara- 
toux  and  Dubousquet-Laborderie  have  succeeded  in  implanting  the  skin 
of  frogs  upon  granulating  wounds  in  man.  The  pigment  disappeared  after 
ten  days,  and  the  graft  took  on  more  and  more  the  appearance  of  human 
skin. 

§  43.  Plastic  Operations  on  other  Tissues  (Tendons,  Nerves,  Mus- 
cles, Bones). — Plastic  opei'ations  and  graftings  are  performed  not  only 
upon  the  external  cutaneous  surface  of  the  body,  but  also  upon  other 
tissues,  such  as  tendons,  muscles,  nerves,  and  bones.  We  shall  refer 
to  this  in  detail  later  on.  At  present  tlie  following  brief  account  will 
suffice :  Defects  or  loss  of  substance  in  a  tendon  can  be  remedied  by 
cutting  flaps  with  pedicles  from  one  or  both  divided  ends  of  the 
tendon  and  bending  them  back  and  uniting  them  by  means  of  sutures 
of  catgut. 

Loss  of  substance  in  a  tendon  may  also  be  remedied  by  filling  the 
intervening  space  with  threads  of  catgut  or  silk,  which  act  as  a  frame- 
work for  the  tendon  tissue  that  is  to  be  newly  formed.  The  same 
method  can  be  used  in  the  case  of  nerves.  Attempts  have  been  made 
to  remedy  defects  in  nerves,  muscles,  and  tendons  by  means  of  corre- 
sponding tissues  taken  from  animals — a  rabbit,  for  instance.  But  these 
transplanted  portions  of  nerves,  tendons,  and  muscles  never  heal  in 
place  permanently  as  sucb.  The  transplanted  portion  of  a  nerve  acts 
merely  as  a  guide  for  the  newly  formed  nerve  fibres  growing  from  the 
proximal  toward  the  distal  end  of  the  injured  nerve.  A  transplanted 
portion  of  muscle  is  always  cast  off  or  is  absorbed  (Yolkmann). 

Defects  in  bone  have  been  remedied  by  living  and  dead  bone.  The 
best  method  of  osteoplasty  consists  in  the  use  of  a  pedunculated  flap 


§43.]  PLASTIC   OPERATIONS  ON   OTHER  TISSUES.  151 

containing  skin,  periosteum,  and  bone,  or  merely  periosteum  and  bone. 
Defects  may  also  be  filled  in  with  completely  separated  pieces  of  living 
bone,  or  with  different  kinds  of  non-living  material.  Thus,  use  has 
been  made  of  pieces  of  bone  taken  from  young  animals  or  children, 
also  of  decalcified  bone,  sterile  bone,  charcoal,  ivory,  and  of  celluloid 
plates  for  defects  in  the  skull.  For  filling  up  cavities  in  bone,  harden- 
ing materials  have  been  used,  such  as  plaster  of  Paris,  copper  amalgam, 
and  Richter's  cement. 


SECOXD   SECTION. 
THE  METHODS  OF  APPLYING  SURGICAL  DRESSINGS. 


CHAPTEE  I. 

THE    ANTISEPTIC    AND    ASEPTIC    PROTECTIVE    DRESSINGS    FOR    WOUNDS. 

General  principles  governing  the  antiseptic  and  aseptic  dressing  of  wounds. — History. 
— The  typical  Lister  dressing;  its  simplification. — Antisepsis  and  asepsis. — The 
most  commonly  used  antiseptic  or  aseptic  dressing  materials  (gauze,  cotton,  jute, 
lint,  wood  fibre,  moss,  etc.). — The  different  antiseptics ;  their  uses  and  dangers 
(poisoning  from  carbolic  acid,  bichloride  of  mercury,  iodoform,  etc.). — Which  anti- 
septics are  of  value  ? — Which  antiseptic  and  aseptic  methods  of  dressing  are  the 
best  ? — Antiseptic  and  aseptic  change  of  dressings. 

§  44.  General  Principles  governing  Antiseptic  or  Aseptic  Dressings.— 

After  learning,  in  the  previous  section,  the  main  principles  governing 
the  modern  aseptic  method  of  performing  operations,  we  come  to  the 
question  of  what  dressings  should  be  used  for  covering  the  wound, 
and  the  discussion  of  the  methods  of  applying  surgical  dressings.  It 
is  a  part  of  surgical  technique  which  requires  indefatigable  diligence 
and  care.  A  cori*ect  application  of  the  dressings,  and  a  carefully  con- 
ducted after-treatment  of  those  who  have  been  operated  upon  or 
wounded,  are  matters  of  the  greatest  importance. 

As  we  are  aware  that  all  infection  of  the  wound  is  caused  by  micro- 
organisms, by  the  omnipresent  bacteria,  it  follows  that  we  should  con- 
duct the  after-treatment  of  the  wound  in  such  a  way  as  to  preserve  it 
from  the  damaging  effects  produced  by  micro-organisms,  and  with  the 
same  care  that  is  used  in  performing  an  aseptic  operation. 

The  surest  and  simplest  way  of  preventing  subsequent  infection  in 
a  clean,  aseptic  wound — -such  as  one  resulting  from  an  operation — is  to 
cover  it  with  a  germ-free  dressing  which  has  been  sterilised  by  hot 
steam  (see  pages  15,  16).  In  private  practice,  dressings  are  still  much 
used  which  have  been  impregnated  with  antiseptics  like  carbolic  acid 
and  bichloride  of  mercury.  That  method  of  treating  a  wound  is  the 
best  which  offers  the  greatest  security  against  subsequent  infection  and 
152 


§44.]   GENERAL  PRINCIPLES  GOVERNING  ANTISEPTIC  DRESSINGS.  153 

most  readily  carries  off  and  absorbs  the  discharge  from  the  wound. 
"We  operate,  without  exception,  according  to  the  rules  of  asepsis,  and 
consequently  the  same  preventive  measures  should  be  carried  out  in 
the  after-treatment  of  the  wound  until  it  has  become  entirely  healed. 
Infected  wounds  are  to  be  cleaned  as  perfectly  as  possible  from  any 
dirt  or  foreign  bodies  which  may  be  present,  and  are  best  disinfected 
by  a  1  to  1,000  solution  of  bichloride  of  mercury. 

Historical  Remarks  on  the  Listerian  Method  of  treating  Wounds.— The 

antiseptic  as  well  as  the  aseptic  occlusive  dressing  for  wounds  has  advanced 
very  gradually  to  its  present  state  of  perfection.  Lister  began  the  use  of  his 
antiseptic  occlusive  dressing  at  the  Grlasgow  hospital  in  1865,  and  published 
his  first  communication  on  the  subject  in  1867.  Thiersch  was  the  first  Ger- 
man surgeon  to  bring  into  notice  Lister's  antiseptic  method  of  treating  wounds, 
describing  it  in  his  work  on  the  repair  of  wounds.*  Then  followed  the  con- 
tributions of  Schultz  and  Von  Lesser,  who  had  in  Edinburgh  itself  made  them- 
selves familiar  with  Lister's  methods  and  praised  them  very  highly.  Even 
before  Lister's  discovery,  antiseptics,  especially  carbolic  acid,  had  been  used 
for  dressings,  but  to  Lister  belongs  the  immortal  honour  of  having  conceived 
and  intelligently  carried  out  the  aseptic  method  of  operating  and  of  apply- 
ing dressings  by  the  use  of  which  it  is  possible  to  keep  fresh  wounds  from 
infection.  In  1872-'73  the  first  trials  were  made  in  Germany  with  the  Lister 
dressing.  In  the  German  Surgical  Congress  of  1874  Volkmann  reported  his 
experiences  with  the  Lister  dressing,  and  in  1875  he  published  his  "  Beitrage 
zur  Chirurgie,"  in  which  were  described  the  remarkable  and  hitherto  unheard- 
of  successes  obtained  by  the  use  of  Lister's  method  of  operating  and  applying 
dressings.  In  1874-'75  the  Listerian  method  came  into  general  use  in  Ger- 
many, and  then  started  on  its  triumphant  progress  over  the  entire  civilised 
world.  Never  was  surgery  so  radically  changed  for  the  better  as  after  the 
introduction  of  Lister's  method  for  the  treatment  of  wounds.  In  the  very 
hospitals  where  the  infectious  wound  diseases  had  raged  the  worst  during  the 
preantiseptic  period,  the  severest  operation  wounds  and  injuries  now  healed 
up  without  suppuration  and  without  secondary  disease.  After  such  remark- 
able success,  the  opponents  of  the  method  who  arose  here  and  there  were 
forced  to  give  up  the  contest. 

The  Original  Typical  Lister  Dressing. — The  typical  Lister  dressing  used 
at  first  was  applied  in  the  following  manner  :  The  disinfectant  was  carbolic 
acid,  used  in  a  two-and-a-half-  to  three-per-cent.  solution  for  non-infected,  and 
in  a  four-  to  five-per-cent.  solution  for  infected  wounds.  Lister  covered  the 
wound,  or,  rather,  the  suture  line,  with  carbolic  acid  and  paraflBne  spread  on 
oiled  silk,  the  whole  being  called  a  "  protective  "  for  keeping  the  irritating 
substances  in  the  dressings  away  from  the  wound.  The  protective  was  made 
of  green  silk  cloth,  painted  over  with  shellac,  and  covered  on  one  side  with  a 
mixture  of  one  part  dextrin,  two  parts  pulverised  starch,  and  fifteen  parts  of 
a  five-per-cent.  carbolic-acid  solution.  Before  using,  the  protective  was  dis- 
infected by  a  three-per-cent.  carbolic  solution.  The  green  colour  of  the  pro- 
tective was  changed  to  black  by  decomposition  of  the  wound-secretion,  which 

*  Pitha-Billroth's  Handbuch  der  Chir.,  Bd.  i,  p.  559. 


154     THE  ANTISEPTIC  AND  ASEPTIC   PROTECTIVE   DRESSINGS. 

was  a  matter  of  practical  importance  for  determining  whether  the  wound  was 
perfectly  aseptic  or  not.  Besides  the  silk  protective,  a  cotton  protective  was 
also  in  use.  Over  the  protectives  Lister  placed  eight  or  more  layers  of  dry 
gauze  impregnated  with  carbolic  acid,  and  between  the  two  outermost  layers 
he  inserted  a  water-tight  material  made  of  cotton  and  gutta-percha  (mack- 
intosh). The  layers  of  carbolised  gauze  extended  some  distance  beyond  the 
limits  of  the  wound,  particularly  when  considerable  discharge  was  expected. 
Lister  used  carbolised  gauze  bandages  instead  of  the  ordinary  strong  muslin 
bandages.  He  impregnated  them  with  carbolic  acid  in  the  same  way  as  the 
gauze  compresses  used  in  the  dressing.  The  tyjjical  Lister  dressing  was 
always  put  on  and  changed  in  the  early  days  under  the  carbolic  spray  (see 
page  14). 

Improvements  in  the  Original  Lister  Dressing. — Very  soon  after  its  intro- 
duction. Listers  carbolised  gauze  dx'essing  was  materially  simplified  and  im- 
proved, particularly  by  German  surgeons.  The  carbolic  spray  used  during 
the  change  of  the  dressings  was  done  away  with,  also  the  protective  and  the 
mackintosh.  The  wound  is  now  covered  only  with  aseptic  dressings,  and 
stress  is  laid  upon  the  importance  of  having  the  secretion  from  the  wound 
dry  quickly  in  the  dressing.  In  place  of  the  dressings  impregnated  with 
antiseptics,  we  now  use  those  which  have  been  sterilised  by  steam  at  a  tem- 
perature of  100°-130°  C.  The  use  of  antiseptics  has  been  curtailed  more  and 
more.  The  instruments  are  sterilised  by  boiling  them  for  five  minutes  in  a 
one-per-cent.  soda  solution,  and  bichloride  of  mercury  1  to  1,000-5,000  is  used 
as  the  antiseptic  for  the  wound.  Sterilised  water,  or  a  sterilised  six-tenths- 
per-cent.  solution  of  common  salt,  is  used  a  great  deal  during  operations,  par- 
ticularly in  the  peritoneal  cavity,  etc.  (see  §  6). 

§  45.  The  Most  Common  Antiseptic  and  Aseptic  Dressings  for 
Wounds. — The  modern  surgeon  uses  particularly  : 

1.  Antiseptic  solutions  for  cleansing  the  wound  and  for  disinfect- 
ing the  materials  used  in  the  dressings.  The  most  suitable  are  three- 
to  five-per-ceut.  solutions  of  carbolic  acid,  and  aqueous  solutions  of 
bichloride  of  mercury  (1  to  1,000-5,000).  He  also  uses  antiseptic  pow- 
ders, such  as  iodoform,  dermatol,  bismuth,  and  naphthalene,  for  dust- 
ing over  wounds,  especially  if  they  have  the  form  of  a  cavity  or  are 
not  closed  by  sutures,  or  are  already  suppurating  or  granulating. 
Instead  of  antiseptic  solutions,  sterile  salt  solution  and  sterile  water 
are  used  upon  the  wound. 

2.  Ahsoi'ljent  raaterials,  such  as  unstarched  gauze,  mull,  jute,  pre- 
pared moss,  wood  wool,  my  own  specially  prepared  wool,  and  cotton 
from  which  all  fatty  matter  has  been  extracted.  These  are  sterilised 
by  subjecting  them  to  steam  heat  at  a  temperature  of  100°-130°  C. 
in  a  sterilising  apparatus. 

The  dressing  materials  impregnated  with  antiseptics,  like  carbo- 
lised and  bichloride  gauze,  were  formerly  in  very  general  use ;  but  it  is 
simpler  and  better  to  sterilise  them  all  by  heating  them  as  just  described, 


§45.]    THE  MOST  COMMON  ANTISEPTIC  AND  ASEPTIC  DRESSINGS.    155 

at  a  temperature  of  100°-130°  C.  in  a  sterilising  apparatus.  More- 
over, it  has  been  proved  that  dressing  materials  impregnated  with 
antiseptics  and  kept  in  a  dry  condition  do  not  remain  sterile,  but  after 
a  time  all  sorts  of  bacteria  have  been  cultivated  from  them  (Schlange, 
Ehlers,  and  others). 

The  modern  surgeon  no  longer  uses  for  dressing  wounds  the  mate- 
rial called  charpie,  which  was  formerly  much  in  vogue,  and  consisted 
of  bundles  of  thread  made  by  pulling  to  pieces  bits  of  linen  cloth. 
This  charpie  has  caused  much  harm ;  it  was  full  of  dirt  and  wound 
poisons,  and  consequently  has  killed  many  a  patient  by  exciting  sup- 
puration and  infectious  wound  diseases  (erysipelas,  pygemia,  septi- 
caemia). 

The  dressing  materials  are  fastened  in  place  by  mull  bandages  which 
have  been  soaked  in  a  three-per-cent.  carbolic  or  1  to  1,000  bichlo- 
ride solution,  and  gauze  bandages  are  apphed  over  these.  The  band- 
ages subsequently  dry  and  cause  the  whole  dressing  to  form  a  firm,  well- 
fitting  support.  When  it  is  necessary  to  immobilise  an  extremity,  the 
dressing  may  be  strengthened  by  adding  splints  of  wood,  metal,  wire, 
or  thin  pliable  wooden  hoops. 

Of  the  numerous  materials  used  for  making  aseptic  and  anti- 
septic dressings,  the  following  are  in  most  common  use  : 

Mull  or  Gauze. — The  most  extensively  employed  material  is  soft,  unfin- 
ished gauze  or  mull.  Mull  is  a  most  excellent  substance  for  dressings,  being 
soft  and  a  good  absorbent,  but  is  somewhat  expensive.  It  is  impregnated 
with  every  kind  of  antiseptic,  particularly  bichloride  of  mercury,  carbolic 
acid,  and  iodoform,  but  it  is  best  sterilised  by  subjecting  it  to  steam  heat  at 
100°  C.  (212°  F.),  as  we  have  described.  For  the  method  of  preparing  this  or 
that  particular  kind  of  antiseptic  gauze — e.  g.,  carbolised,  or  bichloride,  or 
iodoform  oauze,  etc. — reference  is  made  to  the  description  of  the  various  anti- 
septics which  is  given  farther  on. 

Other  and  cheaper  materials  are  recommended  as  substitutes  for  the  more 
expensive  mull ;  these  are  jute,  moss,  prepared  moss,  wood  wool,  etc. 

Cotton.— Cotton  is  not  suitable  for  placing  directly  upon  the  wound,  as  it 
does  not  sufficiently  absorb  the  secretion  from  the  wound,  and  allows  it  to 
collect  underneath  and  decompose.  But  after  covering  the  wound  with  a 
thick  layer  of  some  absorbent  material,  like  mull  or  the  author's  prepared 
wool,  it  is  then  a  good  plan  to  use  dry  cotton,  which  has  been  freed  from 
fat,  as  the  outermost  covering  of  the  dressing. 

Lint— Lint  has  been  manufactured,  especially  in  England,  since  about 
the  beginning  of  the  present  century.  In  combination  with  antiseptic  sub- 
stances, especially  boric  acid  (making  boric  lint),  it  is  very  much  used  as  an 
antiseptic  material  for  dressings. 

Jute.— Jute,  also  called  Indian  hemp,  consists  of  the  woody  fibres  of  the 
difleerent  kinds  of  corchorus,  particularly  the  Corchorus  capsularis,  a  plant 
growing  in  the  East  Indies  and  China.     It  is  an  excellent  substitute  for  cot- 


156     THE  ANTISEPTIC  AND  ASEPTIC  PROTECTIVE  DRESSINGS. 

ton.  It  is  best  used  in  the  sliape  of  jute  pads — that  is,  jute  sewed  up  in  bags 
of  sterilised  gauze. 

Flax. — Fhix  is  recommended  by  Medwedew,  Makuschina,  and  otliei-s.  It 
is  usually  made  up  into  small  bundles,  which  ai*e  boiled  in  lye  for  three 
hours  and  then  left  to  stand  in  the  same  liquid  for  eight  to  ten  hours  longer. 
After  washing  it  five  to  seven  times  in  clean  water,  the  flax  is  dried  and 
combed,  and  finally  becomes  a  completely  white,  soft,  and  delicate  material 
whicli  is  very  absorbent,  and,  like  jute,  is  used  in  the  form  of  small  pads. 
Flax  is  about  five  or  six  times  cheaper  than  cotton. 

Peat. — Neuber  recommends  peat,  having,  by  chance,  observed  a  com- 
pound fracture  of  the  forearm  which  healed  perfectly  under  softened  peat 
which  had  been  applied  to  it.  Peat  dressings  have  now  gone  entirely  out 
of  use. 

Peat  Cotton. — Redon  has  made  from  peat  a  material  like  cotton,  or 
rather  tow,  which  Lucas-Champoniere  considex's  suitable  as  a  dressing  for 
wounds,  on  account  of  its  softness,  its  gi-eat  power  of  absorption,  and  its 
cheapness. 

Moss.— Leisrink  recommends  ordinary  moss  as  a  most  excellent  material 
for  dressings,  combining  in  itself  all  the  advantages  whicli  a  dressing  should 
possess.  It  is  soft,  has  great  power  of  absorption,  and  is  cheap.  The  dry 
moss  should  be  sterilised  by  heating  it  to  a  temperature  of  100°  to  130°  C,  and 
then  placed  in  the  dry  state  in  sterilised  gauze  bags.  The  wound  is  covered 
with  dry  sterile  gauze.  Hagedorn  has  also  i*ecommended  moss  as  a  good 
material  for  dressings.  The  moss  should  be  collected  from  the  woods,  jjicked 
apart,  dried,  and  then  heated  in  an  oven  for  several  hours  at  a  temperature 
of  100°  to  130°  C.  ' 

Moss  Felt. — Leisrink  has  recoinmended  tablets  of  moss  felt  in  the  place  of 
moss  cushions.  The  preparation  of  the  felt  is  as  follows :  The  freshly  gath- 
ered moss  is  pulled  apart,  washed,  and  then  steeped  in  water,  after  which  it 
is  made  into  felt  and  put  in  a  press.  According  to  the  greater  or  less  amount 
of  moss  used,  thick  or  thin  tablets  are  made  which  consist  of  hard  or  soft  felt 
depending  upon  the  pressure  exerted  upon  the  pulp.  The  dried  felt  can  be 
sewed  up  in  gauze  bags  of  different  sizes  and  shapes.  Hagedorn's  moss  pulp 
and  moss-gauze  pulp,  soaked  immediately  before  use  in  sterilised  salt  solu- 
tion, water,  or  bichloride,  are  excellent  materials. 

Wood  Wool. — P.  Bruns  and  Walcher  use  for  dressings  wood  wool  or 
wood  which  has  been  rubbed  into  small  particles  by  a  grindstone.  This 
material  has  great  powers  of  absorption,  is  light,  soft,  and  cheap.  Wood 
wool  is  packed  into  gauze  bags,  and  used  for  dressings  in  the  shape  of  wood- 
wool cushions.  This  dressing  is  simplified  by  combining  with  the  wood  fibre 
a  twenty-per-cent.  admixture  of  ordinary  cotton  wool,  thus  rendering  the 
preparation  of  wood-wool  cushions  superfluous.  The  wood-wool  dressings 
are  remarkable  for  their  great  absorptive  powers,  and  they  can  be  left  in 
place  upon  large  wounds  for  two  to  three  weeks,  and  the  secretions  from  the 
wound  will  become  dry  during  this  time.  The  wound  is  covered  with  a 
layer  of  gauze  in  order  to  j)revent  the  dressing  from  adhering. 

Wood  Fibre. — Kiimmel  has  recommended  wood  fibre  for  an  antiseptic 
dressing  material.  It  is  made  from  pine  or  fir  needles,  and  forms  a  dry, 
green  substance  made  up  of  fine  fibres.     It  is  sewed  up  into  gauze  bags. 


§46.]  THE  DIFFERENT  ANTISEPTICS.  I57 

Wood  Wadding. — Ronnberg  recommends  wood  wadding,  which,  is  a  sub- 
stance made  during  the  process  of  manufacturing  paper.  It  is  pure  cellulose, 
or  a  brown,  woody  material  in  a  finely  divided  state. 

Marly  Scraps. — Tolmatschew  has  recommended  marly  scraps  as  an  ex- 
tremely cheap  material  for  dressings.  It  is  a  product  in  the  manufacture  of 
marly  or  Scotch  gauze,  and  consists  of  thready  scraps  made  in  tearing  off 
tangled  threads.     Wolynzer  recommends  asbestos. 

Paper  Wool. — I  can  recommend  paper  wool  as  an  excellent  absorbent 
material,  and  one  which  forms  a  soft  dressing,  very  comfortable  for  the 
patient.  It  is  made  in  the  manufacture  of  paper  from  cloth  and  is  cheaper 
than  mull. 

Maas  claims  that  the  absorbent  powers  of  dressings  can  be  increased  very 
perceptibly  by  the  addition  to  them  of  such  hygroscopic  substances  as  gly- 
cerine or  common  salt,  and  thus  those  dressings  which  have  but  little  power 
of  absorption,  such  as  cotton,  tow,  jute,  etc.,  can  be  materially  improved — a 
consideration  which  would  be  of  much  value,  particularly  during  war  times. 

Glass  Wool. — Glass  wool,  a  substance  having  very  delicate  fibres  and 
easily  sterilised,  was  at  one  time  used  in  place  of  Lister's  protective  for  cov- 
ering the  wound. 

§  46.  The  Different  Antiseptics. — Of  the  various  antiseptics  which 
are  employed  in  the  treatment  of  wounds  and  for  dressing  purposes, 
carbolic  acid  and  bichloride  of  mercury  are  the  most  widely  used. 
Carbolic  acid  is  the  antiseptic  which  is  most  intimately  connected  with 
the  reform  in  modern  surgery,  and  was  chosen  by  Joseph  Lister  from 
among  all  the  antiseptic  drugs  known  at  that  time  as  the  best  adapted 
for  carrying  out  his  new  methods.  Since  the  introduction  of  asepsis 
the  employment  of  antiseptics  has  diminished  a  great  deal. 

Carbolic  Acid. — Carholic  acid  or  phenol  (CjHgO)  was  isolated  by 
Eunge,  in  1834,  from  coal  tar.  It  forms  colourless  crystals,  and  is 
volatile,  very  caustic,  and  soluble  at  ordinary  temperature  in  15  parts 
water.  It  is  very  poisonous  to  animals  and  plants.  It  is  ordinarily 
used  in  the  form  of  a  two-and-a-half-  to  three-per-cent.  aqueous  solu- 
tion for  cleansing  a  wound,  disinfecting  instruments,  for  washing  oiit 
pads  or  sponges  during  an  operation,  for  a  spray,  or  for  the  hands. 
The  stronger  five-per-cent.  solution  is  used  for  wounds  already  infected, 
but  always  with  caution  on  account  of  the  danger  of  poisoning.  The 
five-per-cent.  solution  should  invariably  be  subsequently  washed  away 
by  a  three-per-cent.  solution.  Moreover,  the  three-  to  five-per-cent. 
solutions  are  serviceable  for  disinfecting  the  field  of  operation,  for 
storing  sponges,  silk,  catgut,  etc.  Five-  to  ten-per-cent.  carbolised 
glycerine  is  used  in  the  same  way.  Laplace  has  increased  the  solu- 
bility and  the  disinfecting  power  of  carbolic  acid  by  the  addition  of 
crude  sulphuric  acid;  he  forms  a  mixture  consisting  of  twenty -five- 
per-cent.  crude  carbolic  acid  with  an  equal  amount  of  crude  sulphuric 


158     THE   ANTISEPTIC  AND   ASEPTIC   PROTECTIVE  DRESSINGS. 

acid  of  a  similar  strength,  and,  after  heating  it,  allows  the  mixture  to 
cool  off.  The  same  result  is  obtained  bj  the  addition  of  a  two-per- 
cent, solution  of  hydrochloric  acid.  At  present  we  avoid  washing  out 
a  wound  with  a  three-  to  five-per-cent.  solution  of  carbolic— a  practice 
which  was  formerly  much  in  vogue — as  we  now  know  that  it  is  unne- 
cessary and  even  dangerous  in  the  case  of  large  wounds.  It  should 
always  be  borne  in  mind  that  carbolic  acid  is  a  powerful  irritant  to  the 
tissues,  and  is,  furthermore,  poisonous.  Children  and  angemic  and 
cachectic  individuals  are  particularly  prone  to  carbolic-acid  poisoning. 
A  warning  should  be  given  here  against  the  prolonged  use  of  wet 
dressings  of  one-  to  five-per-cent.  carbolic.  Gangrene  may  easily 
result  from  their  use,  particularly  on  the  fingei's  and  toes. 

Carbolised  Glycerine. — Carbolised  glycerine  is  an  excellent  disin- 
fectant for  instruments  and  the  hands  of  the  operator.  It  consists  of 
glycerine  containing  ten  to  twenty  per  cent,  of  carbolic  acid.  We 
smear  the  finger  with  five-per-cent.  carbolised  glycerine  or  carbolised 
vaseline  for  making  rectal  or  vaginal  examinations. 

Carbolised  Gauze. — Carbolised  gauze,  which  was  at  one  time  used  a 
good  deal,  is  prepared  as  follows :  500  grammes  of  gauze  is  impreg- 
nated with  a  mixture  containing  1,000  parts  alcohol,  200  parts  colo- 
phonium,  20  parts  castor  oil,  and  50  parts  carbolic  acid. 

Carbolic-Acid  Poisoning. — Carbolic  acid  is,  as  has  been  said,  poisonous, 
and,  even  when  used  externally,  can  produce  dangerous  symptoms  which 
may  terminate  in  death.  I  once  saw  a  very  rapidly  fatal  case  of  poisoning- 
in  a  student.  A  friend  gave  him  a  teaspoonful  of  five-per-cent.  carbolic 
acid  by  mistake,  and  unfortunately  the  stomach  pump  was  not  used  by  the 
physician  called  in.  In  another  similar  case  the  patient  was  saved  by  imme- 
diately washing  out  the  stomach. 

The  symptoms  of  carbolic-acid  poisoning  are  headache,  dizziness,  nausea, 
and  vomiting.  The  change  in  the  colour  of  the  urine  to  olive  green  or  black 
is  an  important  symptom  in  making  the  diagnosis.  Bixt  the  intensity  of  the 
poisoning  bears  no  constant  relationship  to  the  intensity  of  the  discoloration 
of  the  urine.  With  even  strikingly  dark  urine  the  patient  may  feel  very 
well.  The  carbolic  acid  is  found  in  the  urine  in  the  form  of  phenol-sul- 
phuric acid.  In  the  most  severe  cases  there  ensue  bloody  diarrhoea,  haemo- 
globinuria,  and  symptoms  of  collapse,  and  convulsions  caused  by  the  increased 
reflex  excitability  of  the  spinal  cord  (Salkowsky,  Gies) ;  then  follows  a 
marked  fall  of  temperature,  the  pupils  react  slowly  or  not  at  all,  the  respira- 
tion becomes  superficial,  consciousness  is  lost,  and  death  takes  place  from 
paralysis  of  the  vasomotor  centre  in  the  medulla.  In  the  case  of  children 
and  weakly  individuals,  the  external  application  of  carbolic  acid  should  be 
used  with  great  caution.  Furthermore,  many  apparently  strong  individuals 
are  very  susceptible  to  this  drug. 

Clinically  two  distinct  forms  of  phenol  poisoning  are  recognised — acute 
carbolic-acid  poisoning,  and  the  chronic,  which  takes  the  form  of  a  maras- 


§46.]  THE  DIFFERENT  ANTISEPTICS.  I59 

mus  (Falksou,  Czerny,  Kiister).  The  chronic  poisoning  is  characterised  by- 
headache,  hiccough,  debility,  and  loss  of  appetite — symptoms  which  were  of 
frequent  occurrence  among  surgeons  who  operated  very  much  under  the 
carbolic  spray.  Falkson  assisted  at  an  operation  for  two  and  a  half  hours 
where  a  two-per-cent.  carbolic  spray  was  used,  and  in  the  following  twenty- 
four  hours  he  found  2.06  grammes  of  carbolic  acid  in  his  urine,  an  amount 
fourteen  times  greater  than  the  maximum  dose  of  0.15  gramme  allowed  by 
the  Pharmacopoeia. 

Detection  of  Carbolic  Acid  in  the  Urine.— Millon's  reagent  (a  solution  of 
mercury  in  ordijiary  fuming  nitric  acid)  and  bromine  water  give  a  very 
useful  reaction  with  carbolic  acid  after  the  urine  has  been  previously  acidu- 
lated with  hydrochloric  or  sulphuric  acid  and  then  distilled.  Carbolic  virine 
assumes  a  violet  colour  upon  the  addition  of  chloride  of  iron,  and  if  warmed 
with  Millon's  reagent  it  takes  on  a  purplish-red  colour,  or  with  hypochlorite 
of  sodium  a  dark-brown  colour ;  if  treated  with  bromine  water  a  precipitate 
of  tribromphenol  results.  A  very  good  reaction  for  phenol  is  produced  by 
a  hydrochloric-acid  solution  (hydrochloric  acid  fifty  centimetres,  distilled 
water  fifty  centimetres,  and  calcium  chloride  0.20  gramme)  and  a  pine  stick 
(Hoppe-Seyler,  Tommasi).  Tommasi  describes  it  as  follows :  Equal  quan- 
tities of  urine  and  ether  are  shaken  together,  the  supernatant  liquid  is  then 
decanted  and  the  piece  of  stick  is  soaked  in  it  until  saturated,  when  it  is 
plunged  quickly  into  the  hydrochloric-acid  solution  and  finally  exposed  to 
the  sunlight.  The  ensuing  reaction  consists  in  a  blue  coloration  of  the 
stick ;  but  if  carbolic  acid  was  not  present  in  the  urine  there  will  be  no 
change  in  colour,  or  at  the  most  a  slight  change  to  a  faint  green  colour. 
This  reaction  will  enable  the  slightest  trace  of  carbolic  acid  to  be  recognised 
in  urine  or  water.  If  the  stick  is  exposed  to  the  sunlight  too  long,  the  colour 
eventually  disappears. 

The  Presence  of  Carbolic  Acid  in  the  Different  Organs  after  Poisoning.— 
Hoppe-Seyler  has  measured  the  amounts  of  phenol  contained  in  the  separate 
organs  after  phenol  poisoning,  and  he  has  found  that  the  brain  and  kidneys 
hold  more  than  the  others,  consequently  investigation  should  be  first  directed 
to  these  organs  in  cases  of  suspected  carbolic-acid  poisoning. 

Treatment  of  Carbolic-Acid  Poisoning. — The  treatment  of  poisoning  from 
this  drug  consists  in  stopping  its  use  immediately — for  example,  by  removing 
the  carbolic  dressing.  Sonnenburg  has  recommended  the  internal  admin- 
istration of  Glauber's  salts  (sodium  sulphate)  to  hasten  its  excretion  through 
the  kidneys  in  the  form  of  the  innocuous  sulpho-carbolate  of  sodium.  The 
sulphate  of  sodium  should  be  given  in  large  doses  by  the  mouth  or  rectum, 
though  its  efficacy  is  somewhat  doubtful.  The  rest  of  the  treatment  is  symp- 
tomatic— i.  e.,  the  symptoms  are  treated  as  they  arise,  and  stimulants  and 
large  amounts  of  water  are  given  internally.  If  the  poisoning  is  produced 
by  swallowing  carbolic  acid,  the  stomach  pump  should  be  used  immediately. 

Bichloride  of  Mercury  (corrosive  sublimate,  HgClg,  hydrargyrum 
bichloratum  corrosivum)  is  one  of  the  oldest  drugs,  and,  according  to 
Pearson,  was  known  to  the  Chinese,  who  have  made  it  from  cinnabar 
from  time  immemorial.  Billroth,  Buchholtz,  and  Eobert  Koch  were 
the  first  to  determine  and  make  known  its   great  antiseptic   value. 


100     THE  ANTISEPTIC  AND  ASEPTIC  PROTECTIVE  DRESSINGS. 

Koch  showed  tliat  bichloride  of  mercury,  even  in  the  dilution  of  1  to 
330,000,  completely  arrested  the  growth  of  anthrax  bacilli,  and  in  a 
solution  of  a  strength  of  1  to  1,000-5,000  almost  instantly  killed  the 
anthrax  spores.  As  the  bichloride  is  the  most  poisonous  of  all  the 
salts  of  mercury,  it  was  natural  that  many  surgeons  at  first  would  have 
nothing  to  do  with  it  in  the  treatment  of  wounds.  But  now  it  is  a 
^reat  favourite  among  surgeons,  and  is  almost  always  used  for  disin- 
fecting the  field  of  operation,  the  hands,  and  the  wound,  in  aqueous 
solutions  varying  from  1  to  1,000-5, (»00.  Besides  the  marked  anti- 
septic power  of  bichloride  it  has  the  advantage  of  being  much  cheaper 
than  carbolic  acid.  A  one-fifth-per-cent.  solution  of  bichloride  can  be 
used  for  the  storage  of  silk  (after  boiling  it  half  an  hour  in  a  one-fifth 
per  cent,  bichloride  solution)  and  of  catgut  which  has  been  sterilised 
by  the  method  already  described.  Bichloride  is  unsuitable  for  the  dis- 
infection of  instruments,  as  we  have  seen,  and  for  these  a  three-per- 
cent, solution  of  carbolic  acid,  or  half  to  one  per.  cent,  creosol  are 
employed. 

Sta"bility  of  Bichloride  Solutions. — If  ordinary  water,  which  has  not 
been  distilled,  is  used  for  making  bichloride  solutions,  an  insoluble 
compound  of  mercury  will  separate  after  a  time,  which,  according  to 
Furbringer,  is  a  trioxychloride,  or  a  dioxychloride,  or  a  tetraoxychlo- 
ride,  and  is  thrown  down  by  the  alkaline  carbonates  in  the  water.  For 
preventing  this  precipitation  of  the  bichloride  which  occurs  in  ordinary 
spring  water,  Fiirbringer  recommends  the  addition  of  acids  (salicylic, 
liydrochloric,  and  acetic  acids,  0.5  to  1  gramme  per  litre) ;  Laplace 
recommends  tartaric  acid  (one  part  bichloride,  five  parts  tartaric  acid) ; 
while  Bergmann  and  Angerer  recommend  common  salt  (one  gramme 
sodium  chloi'ide  to  one  gramme  bichloride  of  mercury).  Kronig 
claims  that  the  addition  of  acids  and  sodium  chloride  diminishes  the 
antiseptic  action  of  bichloride.  A  small  amount  of  sodium  chloride 
has  the  least  effect  in  this  particular.  Kronig  reconnnends  that  only 
enough  sodium  chloride  should  be  added  to  tlie  bichloride  as  will 
suffice  to  form  the  easily  soluble  sodium  salt  of  mercurial  chloride 
(JS"a2HgCl4) — i.  e.,  ^  gramme  of  sodium  chloride  to  1  gramme  bichlo- 
ride of  mercury.  The  bichloride  tablets  which  are  in  such  general  use 
should  contain  this  percentage.  Schillinger,  Fiirbringer,  and  Meyer 
have  demonstrated  that  the  stability  of  a  bichloride  solution  dej)ends 
also  upon  whether  the  vessel  in  which  it  is  contained  is  air-tight  or 
not,  and  also  upon  the  amount  of  exposure  to  light. 

Preparation  of  Bichloride  Gauze. — Bichloride  gauze,  which  has  been  used 
much  more  in  the  past  than  it  is  now,  is  made  by  saturating-  g-auze  with  a 
mixture  of  ten  parts  of  bichloride  of  mercury,  five  hundred  parts  of  glycerine, 


§46.]  THE   DIFFERENT   ANTISEPTICS.  161 

ten  hundred  parts  of  alcohol,  and  fifteen  hundi'ed  parts  of  water.  This 
makes  a  mixture  which  is  sufficient  to  saturate  about  sixty  to  seventy  metres 
of  gauze,  which  should  be  dipped  into  it  and  then  dried.  Ordinarily  gauze 
<;ontaining  one  third  per  cent,  of  bichloride  answers  sufficiently  the  purposes 
•of  an  antiseptic  dressing.  Cotton,  jute,  etc.,  can  also  be  impregnated  with 
bichloride  in  the  same  way. 

Bichloride  Poisoning. — As  we  have  previously  remarked,  bichloride  of 
mercury  is  a  dangerous  j^oison,  and  must  be  used  with  vei^y  great  caution, 
■especially  in  the  case  of  children  and  sickly  individuals. '  The  symptoms  of 
poisoning  manifested  after  the  external  exhibition  of  the  drug  consist  in  a 
feeling  of  dizziness,  restlessness,  general  malaise,  vomiting,  salivation,  ulcer- 
ative stomatitis  of  the  gums,  and  toward  the  last  there  is  a  bloody  diarrhcea 
and  occasionally  bleeding  from  the  mouth  and  nose.  The  urine  contains 
mercury  and  albumen.  Locally,  when  the  bichloride  dressing  has  been 
applied,  there  is  sometimes  an  eczema,  with  persistent  itching  and  burning 
of  the  skin,  particularly  if  the  dressings  have  been  put  on  too  wet,  and  this 
should  therefore  be  avoided.  The  lesions  of  bichloride  i^oisoning  are  as  fol- 
lows :  Hypereemia  of  the  kidneys,  marked  changes  in  the  epithelial  cells  of 
the  kidneys — particularly  the  convoluted  tubules,  but  also  the  straight  ones — 
and  hyaline  casts.  There  are  also  ulceration  and  hypereemia  of  the  small 
intestine,  desquamation  and  ulceration  of  the  large  intestine,  swelling  and 
necrosis  of  the  liver,  calcareous  infarcts  and  crystalline  formations  in  the 
kidney  and  liver,  subendothelial  ha?morrhages  in  the  heart,  and  marked 
swelling  of  the  parenchyma  of  the  spleen.  In  consequence,  of  the  serious 
changes  in  the  kidneys,  complete  suppression  of  urine  may  result,  which 
is  then  to  be  looked  upon  as  the  real  cause  of  death.  In  chronic  bichloride 
poisoning  also  the  changes  in  the  kidneys  are  particularly  characteristic,  and 
may  be  for  a  long  time  the  only  symptom  (Sonnenburg). 

It  is  necessary,  moreover,  to  use  bichloride  of  mercury  carefully  in  the 
interests  of  the  physician  and  of  the  assistants.  Even  then  they  will  occa- 
sionally show  signs  of  poisoning  in  the  form  of  salivation  and  inflammation 
of  the  gums,  or  mercury  and  albumen  will  be  present  in  the  urine.  Since 
asepsis  has  taken  the  place  of  antisepsis  in  operations,  and  we  have  limited 
the  use  of  bichloride,  the  cases  of  poisoning  from  tins  drug,  like  those  from 
■carbolic  acid,  have  become  much  less  common.  One  should  operate  as 
"  dry "  as  possible,  and  avoid  irrigating  and  washing  out  the  wound  with 
bichloride  solutions  whenever  this  can  be  done,  and  use  only  dressings  which 
have  been  sterilised  by  steam,  etc.  Operations  in  the  thorax,  peritoneal 
cavity,  rectum,  and  vagina  must  be  conducted  with  very  great  care  as  regards 
the  use  of  bichloride,  and  the  latter  should  not  be  employed  for  washing  out 
the  pleural  cavity  after  an  operation  for  empyema,  nor  for  irrigating  the 
uterus  or  rectum,  etc. 

Treatment  of  Bichloride  Poisoning.— The  treatment  of  poisoning  by 
bichloride  of  mercury  consists  in  immediately  stopping  its  use;  the 
rest  is  symptomatic — i.  e.,  treatment  of  symptoms  as  they  arise. 

Salicylic  Acid.— Salicylic  acid  (C7H6O3)  exists  in  the  form  of  small  needle- 
shaped  crystals,  which  are  odourless,  and  only  slightly  soluble  in  cold  water 
<1  to  300-400),  but  readily  soluble  in  hot  water,  alcohol,  ether,  or  glycerine. 
12 


162     THE  ANTISEPTIC  AND  ASEPTIC  PROTECTIVE  DRESSINGS. 

Salicylic  acid  is  not  volatile  like  carbolic  acid,  from  which  it  is  made  syn- 
thetically bj^  treating  carbolate  of  sodium  with  carbonic-acid  gas  at  a  tem- 
perature of  150°  C.  By  the  absorption  of  carbonic  acid  the  basic  sodium 
salt  of  salicylic  acid  results,  and  the  former  treated  with  hydrochloric  acid 
produces  salicylic  acid. 

Aside  from  its  internal  administration,  salicylic  acid  is  extensively  used 
in  surgery  as  a  dusting  powder  for  wounds  (Schmidt),  in  solution  (1  to  300) 
for  the  disinfection  of  wounds,  and  particularly  for  continuous  irrigation, 
and  in  disinfecting  ointments  (one  part  acid  salicyl.,  six  parts  cera  alba, 
twelve  parts  paraffine,  twelve  parts  almond  oil).  Salicylic  acid  should  be 
used  with  caution  as  a  dusting  powder  for  wounds  which  are  liable  to  absorb 
large  quantities  of  it,  since  fatal  poisoning  has  thus  been  pi'oduced.  By  add- 
ing borax  to  salicylic  solution  the  solubility  of  the  salicylic  acid  can  be  mate- 
rially increased  without  diminishing  the  effectiveness  of  its  action.  A  very 
useful  solution  for  irrigation  of  wounds  consists  of  one  part  salicylic  acid, 
six  parts  borax,  and  five  hundred  parts  water. 

Acetate  of  Aluminium.— Acetate  of  aluminium,  like  all  the  salts  of  acetic 
acid,  is  a  vei-y  good  antiseptic  (Pinner) ;  Burow,  senior  (1857),  was  the  first 
to  use  it  with  success.  He  prepared  the  substance  from  a  mixture  of  eight 
parts  acetate  of  lead,  five  parts  alum,  and  sixty-four  parts  water,  the  acetate 
of  lead  being  slowly  added  to  the  cold  alum  solution ;  this  precipitated  sul- 
phate of  lead,  leaving  the  acetate  of  aluminium,  though  not  chemically  pure, 
in  solution.  The  solution  should  then  be  filtered.  Acetate  of  aluminium  is 
used  in  the  form  of  one-half-  to  one-per-cent.  solutions  for  continuous  irriga- 
tion and  wet  dressings. 

Aceto-tartrate  of  Aluminium,  an  easily  soluble  double  salt  with  a  strong 
antiseptic  action,  is  used  in  tlie  strength  of  one  half  to  three  per  cent,  for 
antiseptic  wet  dressings,  and  in  the  strength  of  three  to  five  per  cent,  for  the 
disinfection  of  wounds  (Schede,  Kiimmell). 

Thymol,  a  non-poisonous  substance,  is  the  active  principle  of  oil  of  thyme, 
which  is  obtained  from  various  species  of  thyme,  particularly  the  thymus 
vulgaris.  In  1719,  Neumann  isolated  from  oil  of  thyme  a  crystalline,  cam- 
phor-like body  which  he  called  thymol.  The  crystals  are  sparingly  soluble 
in  water,  but  readily  soluble  in  alcohol  and  ether.  Thymol  is  used  in  an 
aqueous  solution  in  the  strength  of  1  to  1,000.  containing,  in  addition  to  the 
water,  ten  parts  of  alcohol  and  twenty  of  glycerine  to  prevent  the  precipita- 
tion of  the  thymol. 

Chloride  of  Zinc. — Chloride  of  zinc  has  been  used  by  some  surgeons  for 
antiseptic  dressings  and  disinfection  of  ^vounds.  Weak  solutions  (2  or  2|- 
to  1,000),  or  stronger  ones  (1-5  to  100),  have  been  used.  It  has  not  come  into 
anything  like  general  use  in  the  treatment  of  wounds,  and  is  chiefly  employed 
as  a  caustic  in  about  an  eight-  to  ten-per-cent.  solution  to  cleanse  fistulous 
tracts,  foul  ulcers,  etc. 

Boric  Acid.— Boric  acid  (H3BO3)  exists  in  the  form  of  flat  crystals,  which 
are  only  slightly  soluble  in  cold  water  (1  to  30),  but  readily  soluble  in  hot 
water  and  in  alcohol.  It  is  usually  employed  in  a  two-  to  three-per-cent. 
solution,  though  for  irrigation  of  wounds  aqueous  solutions  of  a  strength  of 
5-10  to  100  may  be  employed.  Its  antiseptic  action  is  weak,  and,  if  used  too 
energetically,  it  is  not  without  danger.     Molodenkow  observed,  after  ener- 


§46.]  THE  DIFFERENT  ANTISEPTICS.  Igg 

getic  irrigation  of  the  pleural  cavity  and  a  psoas  abscess  with  five-per-cent. 
boric  acid,  vomiting,  erythema  of  the  face,  and  death  from  cardiac  paralysis 
in  both  cases.  He  used,  it  is  true,  a  very  large  amount  (fifteen  kilogrammes) 
of  a  five-per-cent.  solution,  and  the  irrigation  lasted  an  hour.  Schuzer  ob- 
served a  fatal  result  in  a  patient  who  took  fifteen  grammes  of  boric  acid  for 
cystitis.  He  went  into  collapse  a  few  hours  afterwards,  and  died  thirty -six 
hours  later.  The  autopsy  showed,  besides  a  mild  chronic  nephritis,  an  acute 
toxic  degeneration  of  the  kidneys.  The  pre-existing  chronic  nephritis  prob- 
ably predisposed  to  the  fatal  result.  Boric  acid  is  much  used  in  the  form  of 
Lister's  boric  lint,  a  dressing  which  is  non-irritant  and  yet  strongly  antisep- 
tic ;  it  contains  equal  parts  by  weight  of  boric  acid  and  lint,  and  is  applied 
to  the  wound  in  a  dry  or  wet  state.  Boric  lint  is  very  simply  prepared  by 
soaking  lint  in  a  hot  concentrated  boric-acid  solution;  it  is  then  allowed 
to  dry,  causing  the  boric  acid  to  adhere  firmly  to  the  lint  in  the  form  of 
crystals. 

Boric  Ointment. — An  excellent  ointment  is  made  with  boric  acid  consist- 
ing of  three  parts  of  boric  acid,  five  parts  vaseline,  ten  parts  paraffine ;  or 
three  parts  boric  acid,  four  parts  cera  alba,  and  twenty  parts  olive  oil.  A 
.simpler  and  more  stable  mixture  is  one  of  twenty  parts  of  boric  acid  with 
one  hundred  parts  of  vaseline  or  ungt.  glycerini  (known  as  glyceritum  boro- 
glycerini).     Boroglycerin  lanolin  is  another  good  preparation. 

Aseptin. — The  so-called  aseptin  used  in  Sweden  is  a  mixture  of  two  parts 
boric  acid,  one  part  alum,  and  eighteen  parts  of  water ;  it  is  less  irritating 
than  carbolic  acid,  is  not  poisonous,  and  has  no  unpleasant  odour. 

Tetraboride  of  Sodium.— The  tetraboride  of  sodium  (Jaenicke)  is  more 
soluble  and  effective  than  boric  acid,  and  on  account  of  its  non-irritant 
and  non-poisonous  character  can  be  used  in  a  fifteen-  to  seventy-per-cent. 
solution. 

Bismuth. — Bismuth  (subnitrate  of  bismuth)  is  a  white  crystalline  powder 
of  an  acid  reaction,  which  is  only  slightly  soluble  in  water,  and  is  recom- 
mended by  Kocher  for  treating  wounds  and  for  antiseptic  dressings.  Bis- 
muth lessens  the  secretion  from  a  wound  very  perceptibly,  but  it  is  not  an 
innocuous  substance,  as  symptoms  of  poisoning  have  been  produced  when 
used  in  strong  mixtures  (ten  per  cent.)  or  in  large  amounts  ;  these  are  acute 
stomatitis  with  marked  swelling  of  the  gums,  tongue,  and  throat,  and  a  dark 
discoloration  of  the  edges  of  the  gums,  as  in  lead  poisoning,  diarrhoea,  ne- 
phritis accompanied  by  albuminuria,  and,  finally,  dark-coloured  urine. 

Iodoform. — lodofoi-rn  (CHI3)  is  a  bright  yellow  crystalline  powder, 
almost  insoluble  in  water,  acids,  and  alkalies,  but  readily  soluble  in 
ether,  chloroform,  alcohol,  volatile  oils,  and  fats.  About  2.5  to  3 
grammes  of  iodoform  are  soluble  in  one  hundred  grammes  of  olive  oil. 
It  was  first  introduced  in  1853,  and  since  1866  has  been  highly  recom- 
mended as  a  dressing  for  wounds,  particularly  in  syphilitic  cases ;  but 
to  Moleschott,  and  especially  to  Mosetig-Moorhof,  belong  the  honour 
of  introducing  iodoform,  in  1880,  into  general  surgical  use,  and  thus 
enriching  our  methods  of  dressing  wounds  by  a  most  valuable  remedy. 
Authorities  differ  as  regards  the  antiseptic  value  of  iodoform  (see  page 


10 J:     THE  ANTISEPTIC   AND  ASEPTIC  PROTECTIVE  DRESSINGS. 

165).  It  is  poisonous,  and  numerous  fatal  cases  of  poisoning  liave 
occurred  from  its  use,  particularly  at  first  (see  page  166).  It  should 
hence  be  employed  with  great  care  and  not  in  too  large  amounts, 
especially  in  old,  anaemic,  or  cachectic  patients,  in  children,  and  in  in- 
dividuals with  heart  and  kidney  diseases.  But  even  perfectly  sound 
persons  may  have  an  idiosyncrasy  as  regards  iodoform,  and  very  small 
amounts  may  produce  symptoms  of  poisoning.  The  crystalline  form 
should  be  used,  and  not  the  fine  powder,  as  the  latter  is  absorbed  more 
quickly  and  hence  is  more  dangerous  (Giiterbock).  I  use  iodoform  to 
dust  over  unsutured  wounds,  particularly  in  tuberculosis  and  syphilis. 
It  may  be  applied  with  a  brush,  or  blown  over  or  into  the  wound  with 
a  powder  blower,  or  simply  dusted  over  it  through  a  piece  of  gauze. 
I  consider  it  unnecessary  to  dust  iodoform  over  a  wound  which  has 
been  sutured.  It  is  very  useful  in  injuries  and  operations  affecting  the 
nose,  throat,  mouth,  vagina,  and  rectum,  for  syphilitic  and  tubercular 
ulcers,  and  for  many  cases  of  compound  fracture. 

P.  Bruns  and  myself  have  obtained  excellent  results  from  the  injec- 
tion of  a  ten-per-cent.  iodoform  mixture  in  glycerine  or  oil,  in  cases  of 
bone  and  joint  tuberculosis  and  in  cold  (tubercular)  abscesses.  To 
avoid  iodoform  poisoning,  the  iodoform  and  oil  or  glycerine  should  be 
sterilised  separately,  and  then  mixed,  because  in  sterilising  the  mixture 
at  100°  to  130°  C.  in  the  steriliser  too  much  free  iodine  and  iodine 
hydrate  are  liberated.  Glycerine,  being  itself  aseptic,  does  not  need 
sterilisation,  and  non-sterilised  iodoform  glycerine  can  consequently  be 
employed  without  evil  results.  Schellenberg  called  attention  to  the 
possibility  of  glycerine  poisoning  in  the  use  of  iodoform  glycerine 
injections.  A  child,  four  years  of  age,  with  suppurating  hip-joint 
disease,  died  after  the  application  of  sixty  to  sixty -five  cubic  centimetres 
of  glycerine,  with  the  symptoms  of  fever,  rapid  pulse,  coma,  and 
marked  signs  of  irritation  of  the  kidneys.  The  amount  that  can  be 
used  safely  in  the  case  of  children  is  about  ten  cubic  centimetres,  and 
in  adults  from  twenty  to  twenty-five  cubic  centimetres.  Iodoform 
kills  tubercle  bacilli  slowly,  and  hence  has  a  direct  antitubercular 
action.  Moreover,  it  brings  about,  both  by  internal  and  local  use,  fatty 
degeneration.  It  produces  its  action  both  by  setting  iodine  free  and 
by  forming  organic  iodine  compounds.  Its  action  is  to  be  regarded  as 
a  protracted  iodine  action  (Hogyer,  Zeller,  Harnack). 

Iodoform  has  been  mixed  with  other  antiseptic  powders.  Sprengel 
recommends  for  cavities  and  bone  and  joint  tuberculosis  a  mixture  of 
equal  parts  of  iodoform  and  calomel. 

Iodoform  gauze  is  exceedingly  useful,  consisting  of  iodoform  50, 
ether  250,  alcohol  750,  and  gauze  500  parts ;  or  iodoform  50,  resin  20, 


§46.]  THE  DIFFERENT  ANTISEPTICS.  165 

glycerine  5,  and  alcoliol  1,000  parts.  It  is  particularly  valuable  for 
packing  cavities,  but  must  be  used  witli  great  care  in  the  class  of  indi- 
viduals mentioned  above,  as  I  have  seen  symptoms  of  poisoning  after 
the  use  of  iodoform  gauze  alone — for  examjDle,  after  extirpation  of  the 
rectum ;  and  particular  care  must  be  taken  not  to  exert  too  much 
pressure  with  the  bandages  applied  over  a  wound  which  has  been 
packed  with  this  gauze.  Billroth's  sticky  iodoform  gauze  is  best  suited 
for  cavities  where  mucous  membrane  exists,  because  it  adheres  firmly 
to  the  surface  of  the  wound.  It  is  made  by  wringing  out  six  metres 
of  gauze  or  mull  in  a  solution  consisting  of  100  grammes  of  resin,  50 
grammes  of  glycerine,  and  1,200  grammes  of  alcohol  (95  per  cent.), 
and  after  the  gauze  has  dried,  230  grammes  of  iodoform  are  rubbed 
into  it.  . 

I  sometimes  use  in  place  of  iodoform  gauze  the  iodoform  wick  recom- 
mended by  Gersuny.  It  is  prepared  in  the  same  way  as  iodoform  gauze, 
and  can  be  easily  conducted  out  of  the  wound  through  a  small  opening  in 
the  skin. 

An  attempt  may  be  made  to  conceal  the  very  sharp,  saffron-like 
odour  of  iodoform  by  the  addition  of  tincture  of  musk,  bergamot  oil, 
tonka  bean,  or  powdered  coffee,  lodoformin  and  iodoformol  are  two 
odourless  preparations  of  iodoform.  lodoformin,  a  white  powder,  is 
a  compound  of  75  per  cent,  iodoform  and  a  formaldehyde.  Kro- 
mayer  recommends  iodoformogen,  an  odourless  iodoform-albumen 
preparation. 

Iodoform  Drainage  Tubes,  Iodoform  CoUodion,  etc.— The  impregnation  of 
drainage  tubes  with  iodoform  has  been  recommended  ;  they  are  soaked  for 
about  an  hour  in  a  concentrated  solution  of  iodoform  in  ether  and  then 
allowed  to  dry.  Iodoform  is  much  used  in  the  form  of  iodoform  collodion 
(1  to  10),  which  is  employed  in  place  of  the  ordinary  sticking  plaster.  Sticks 
of  iodoform  gelatine  are  now  used  for  fistulae,  chronic  gonorrhoea,  etc. 
Mosetig  recommends  a  fifty-per-cent.  iodoform-glycerine  injection  for  goitre 
and  for  soft  hyperplastic  lymphomata.  Iodoform  sticks  are  prepared  accord- 
ing to  the  following  formula  :  Iodoform  10  parts,  gum  arable,  glycerine,  and 
starch,  of  each  1  part.  They  can  be  more  simply  made  by  mixing  together 
one  part  of  iodoform  and  two  parts  of  cocoa  butter.  We  shall  return  to 
this  subject  later  on  in  its  proper  place.  The  iodoform- ethyl-alcohol  solu- 
tion (1 :  2  :  8)  is  used  a  good  deal  for  parenchymatous  injections  into  tuber- 
cular foci.  .  1    4.-U       ' 

Effect  of  Iodoform  upon  Bacteria.— Kronecker,  Heyn,  Rovsmg,  and  others, 
showed  that  the  Streptococcus  and  Staphylococcus  pyogenes  aureus  as  well 
as  other  bacteria,  may  live  a  long  time  in  iodoform  powder  unharmed. 
The  growth  and  reproduction  of  tubercle  bacilli,  however,  are  diminished  by 
iodoform  and  they  gradually  die.  But  although  iodoform  has  no  direct  in- 
fluence over  most  pathogenic  bacteria,  it  is  known  tliat  it  weakens  the  tox- 


166     THE  ANTISEPTIC  AND  ASEPTIC   PROTECTIVE  DRESSINGS. 

ines  of  various  bacteria,  or  changes  the  toxines  into  harmless  compounds. 
Neisser  showed  that  iodoform  is  decomposed  by  bacteria,  and  that  it  then 
has  an  antiseptic  action.  Of  these  decomposition  products  free  iodine  and 
hydriodic  acid  are  the  most  important.  The  more  pronounced  the  putre- 
faction and  decomposition  in  a  wovmd.  the  more  pronounced  becomes  the 
antibacterial  action  of  iodoform.  According  to  Maurel,  Lomey,  and  others, 
iodoform  stimulates  the  phagocytic  action  of  the  leucocytes.  Marchand  and 
Meyer  state  that  the  formation  of  giant  cells  around  a  foreign  body  is  dimin- 
ished by  the  iodoform,  and  the  cells  of  the  exudate  which  have  wandered 
into  the  foreign  body  are  rapidly  destroyed.  Hence  it  is  better  to  pack  the 
wound  with  iodoform  gauze  than  with  sterile  gauze,  as  the  former  does  not 
adhere  to  the  tissues  and  can  be  removed  more  easily. 

Iodoform  Poisoning. — The  symptoms  of  iodoform  xioisoning  consist 
chiefly  of  cardiac  and  cerebral  disturbances,  particularly  in  the  severer  cases. 
Cardiac  symptoms  are  usually  the  first  to  make  their  appearance.  The 
milder  cases  of  poisoning  are  characterised  by  a  rapiS,  irregular,  small 
pulse ;  by  digestive  and  slight  nervous  disturbances,  such  as  anorexia, 
nausea,  and  finally  vomiting ;  by  headache,  general  malaise,  sleeplessness,  a 
depressed  fi*ame  of  mind,  etc.  In  the  more  severe  cases  of  iodoform  poison- 
ino-  the  symptoms  may  correspond  to  either  one  of  the  two  following 
descriptions : 

(a)  The  pulse  suddenly  becomes  rapid  and  small ;  there  is  sleeplessness, 
great  restlessness,  delirium,  hallucinations,  maniacal  excitement,  and  mel- 
ancholia, with  refusal  to  take  food.  These  symptoms  of  mental  aberration 
can  be  quickly  checked  by  removing  the  iodoform  dressing,  but  they  may 
be  prolonged  for  weeks  even  after  the  iodoform  has  been  stopped.  Some  of 
these  cases  terminate  fatally  from  cardiac  and  respiratory  paralysis. 

(b)  After  a  brief  period  of  excitement  there  follows  a  general  paralysis  of 
the  central  nervous  system,  giving  the  picture  of  a  severe  meningo-encepha- 
litis  (loss  of  consciousness,  deep  sleep,  coma,  involuntary  discharge  of  urine 
and  faeces,  accom]3auied  by  great  muscular  relaxation).  This  is  the  more 
severe  form,  and  nearly  always  terminates  fatally. 

Occasionally  there  is  observed  a  impular  or,  more  commonly,  an  urti- 
caria-like eruption  on  the  skin.  There  is  not  always  a  rise  in  temperature. 
The  pulse  is  usually  greatly  accelerated.  The  length  of  time  that  may 
elapse  between  the  application  of  the  iodoform  dressing  and  the  first  symp- 
toms of  poisoning  varies  very  much.  Sometimes  marked  symptoms  come 
on  during  the  very  day  of  the  operation;  in  other  cases  three  to  five  to  six 
days,  or  even  foui'teen  days,  j)ass  before  they  make  their  appearance.  Iodo- 
form poisoning  is  generally  acute,  but  sometimes  it  takes  a  chronic  or  sub- 
acute course,  and  the  symptoms  may  persist  several  weeks,  although  the 
drug  is  suspended  at  the  very  first  appearance  of  intoxication.  Mikulicz 
saw  one  case  terminate  fatally  after  the  expiration  of  twenty-nine  days. 
The  majority  of  cases  of  iodoform  poisoning  have  occurred  in  old  people. 
In  the  latter  all  the  organs,  particularly  the  heart  and  kidneys,  are  less 
active,  and  consequently  poisoning  is  more  likely  to  occur.  In  children  the 
danger  of  poisoning  is  much  less. 

Explanation  of  Iodoform  Poisoning.— The  symptoms  of  iodoform  poison- 
ing are  due  chiefly  to  the  action  of  free  iodine  or  of  organic  iodine  com- 


^46.]  THE   DIFFERENT   ANTISEPTICS.  16Y 

pounds.  Iodine  is  set  free  at  the  point  of  application  of  the  iodoform,  and  is 
absorbed  by  the  blood  in  the  form  of  alkaline  iodide  and  the  albuminate  of 
iodine.  The  albuminate  of  iodine  decomposes  in  the  system,  forming-  organic 
substances  containing  iodine,  which  are  excreted  in  the  urine  together  with 
the  alkaline  iodides.  x4-ccording  to  Harnack  and  Ludwig,  the  general  symp- 
toms of  iodine  poisoning  are,  in  fact,  chiefly  produced  by  the  iodine  in  the 
form  of  an  albuminate  of  iodine,  or  by  the  organic  compounds  of  iodine.  It 
is  well  known  that  the  alkaline  iodides  can  be  introduced  into  the  system  in 
very  large  amounts  without  causing  the  general  symptoms  of  iodine  poison- 
ing. Zeller  claims  that  only  a  fractional  part  of  the  iodine  is  excreted  in  the 
urine  and  faeces  while  the  rest  remains  in  the  system  ;  and  thus  he  explains 
how  iodoform  x^oisoning  may  sometimes  first  make  its  appearance  after  the 
expiration  of  two  to  three  weeks.  If  this  substance  is  then  employed  in  too 
large  amounts,  and  circumstances  favour  its  absorption,  and  if  there  is 
diminished  excretion  of  iodine  on  account  of  disease  of  the  kidneys  or  heart, 
while  the  blood  is  both  qualitatively  and  quantitatively  deficient,  under  such 
circumstances  poisoning  is  apt  to  make  its  appearance  rapidly  and  to  run  an 
acute  course,  terminating  in  death.  As  a  means  of  preventing  to  a  certain 
degree  this  general  poisoning  of  the  whole  system,  Harnack  takes  the  pre- 
caution of  applying  with  the  iodoform  some  harmless  alkali  in  the  locality 
where  the  former  is  used,  so  as  to  favour  the  formation  of  an  alkaline  iodide 
from  the  free  iodine  which  is  split  off  fx'om  the  iodoform. 

Mosetig-Moorhof,  in  his  large  experience,  has  never  seen  a  single  case  of 
iodoform  poisoning,  attributing  it  to  the  fact  that  he  never  uses  iodoform 
except  in  small  amounts,  never  applies  dressings  in  which  it  exists  so  as  to 
exert  pressure,  and  changes  them  as  infrequently  as  possible  and  without 
irrigation  of  the  surface  of  the  wound.  He  also  considei^s  it  dangerous  to 
use  carbolic  acid  simultaneously  with  iodoform  in  dressings,  because  the 
carbolic  acid  may  produce  an  inflammation  of  the  kidneys  amounting  to  an 
actual  nephritis  (nephritis  carbolica),  and  thus  retard  the  excretion  by  the 
urine  of  the  iodoform  which  has  been  absorbed,  or,  in  other  words,  cause  it 
to  be  retained  in  the  blood,  These  statements  of  Mosetig-Moorhof  are  con- 
firmed by  the  expeinments  of  Holger  Mygind,  who  found  that  in  all  cases 
in  which  iodoform  and  carbolic  acid  were  used  together  the  iodine  reaction 
was  given  in  the  urine  rather  later  than  usual,  the  longest  time  necessary 
for  it  to  appear  being  twenty-seven  hours  after  ingestion,  the  shortest  four 
hours,  or  the  iodine  was  detected  in  the  urine  only  after  all  traces  of  car- 
bolic acid  had  vanished.  Moreover,  Holger  Mygind  claims  that  the  albumi- 
nuria that  appears  during  the  use  of  iodoform  is  only  produced  by  the 
simultaneous  use  of  carbolic  acid.  It  is  of  some  practical  value  to  note  that 
the  excretion  of  iodine  is  continued  for  a  considerable  length  of  time  after 
the  use  of  iodoform  has  been  suspended  ;  for  instance,  one  gramme  of 
iodoform  gave  rise  to  a  reaction  for  iodine  for  twenty-two  days,  and  fifteen 
grammes  gave  the  iodine  reaction  in  the  urine  for  thirty-eight  days,  etc. 
The  size  of  the  wound  has  a  great  influence  upon  the  rapidity  of  the  absorp- 
tion of  iodoform.  Granulating  woimds  absorb  it  more  quickly  than  fresh 
wounds,  and  wounds  in  which  fat  is  abundant  take  it  up  very  rapidly. 
According  to  Binz,  the  iodoform  is  dissolved  by  the  small  particles  of  fat. 

As  we  have  before  remarked,  iodoform  produces  marked  cerebral  and 


168      THE   ANTISEPTIC   AND   ASEPTIC   PROTECTIVE   DRESSINGS. 

cardiac  distiirbauces.  liaviiig  a  narcotic  effect  upon  animals  (dogs  and  cats)^ 
and  causing  death  by  paralysis  of  the  heart  and  respiration  (Binz,  Hag'3'er). 
Aschenbrandt  brought  about  a  fata]  pneumonia  by  causing  animals  to  inhale 
iodoform  vapour.  The  post-mortem  examination  in  these  cases  revealed  ad- 
vanced fatty  degeneration  of  the  heart,  livei*,  and  kidneys.  Post-mortem, 
examinations  of  the  human  subject  dying  from  iodoform  poisoning  reveal 
a  similar  fatty  degeneration  of  tliese  organs,  and  in  addition  either  no  change 
in  the  brain  or  an  tedema  of  the  pia  mater. 

Treatment  of  Iodoform  Poisoning. — Besides  the  immediate  removal  of  the 
iodoform  dressing,  the  treatment  of  iodoform  j^oisoning  is  purely  symp- 
tomatic. In  the  worst  cases  no  treatment  has  proved  of  any  avail.  Very- 
alarming  symptoms  are  apt  to  make  their  appearance  suddenly  without  any 
prodromata.  It  is  impossible  to  state  the  smallest  amount  of  iodoform  which 
may  be  used  with  impunity,  as  the  dosage  varies  for  each  individual.  One 
gramme  of  iodoform  has  been  known  to  produce  a  transient  delirium  ;  and 
Seeligmiiller  observed  melancholia  with  hallucinations  thirty  days  after  the 
administration  of  six  grammes  of  iodoform  ;  and  five  grammes  caused  the 
death  of  one  of  his  cases,  a  woman  thirty-six  years  of  age.  I  lost  one  case  in 
which  a  goitre  was  removed,  and  another  in  which  a  carcinomatous  larynx 
was  extirpated,  in  each  of  which  cases  I  employed  about  five  grammes  of 
the  powdered  drug  together  with  the  iodoform  in  the  iodoform  gauze  used 
for  packing  the  wound.  In  still  another  case,  a  strong  man  fifty  years  of 
age,  I  saw  alarming  symptoms  follow  a  simple  dusting  of  the  suture  line 
after  a  laparotomy,  with  four  to  six  grammes  of  iodoform  ;  stupor,  great, 
restlessness,  maniacal  excitement,  rapid,  small  pulse,  etc.,  were  present,  but 
after  four  weeks  complete  recovery^  took  place.  Of  course  the  dressings 
were  removed  at  the  very  first  appearance  of  the  symptoms.  The  poi.soning^ 
was  doubtless  caused  by  the  excessive  sweating  to  which  the  patient  was- 
subject  during  the  hot  da^ys  in  July. 

Detection  of  Iodine  in  the  Urine.— For  detecting  iodine  in  the  urine  there 
are  the  following  four  methods  : 

1.  The  flixid  to  be  tested  is  mixed  with  a  little  starch  paste,  dilute  sul- 
phuric acid,  and  a  drop  of  fuming  nitric  acid,  after  which  there  results  a 
bluish  colour,  w^hich  may  change  into  dark  blue  according  to  the  amount  of 
iodine  present.  This  colour  disappears  on  warming  the  mixture,  and  reap- 
pears when  it  has  cooled  off  again. 

2.  The  fluid  is  mixed  with  dilute  sulphuric  acid  and  a  drop  of  fuming 
nitric  acid,  and  then  shaken  with  chloroform,  in  which  the  iodine  is  soluble, 
producing  a  violet  colour.  Chloride  of  lime  can  be  used  instead  of  the  nitric 
acid,  and  bisulphide  of  carbon  instead  of  cliloroform. 

3.  Upon  the  addition  of  equal  parts  of  oleum  terebinthinae  and  guaiacol 
to  an  equal  amount  of  urine  there  results  a  deep-blue  colour  if  iodine  is 
present. 

4.  To  the  fluid  is  added  a  little  starch  paste,  dilute  sulphuric  acid,  fuming 
nitric  acid,  and  a  few  drops  of  bisulphide  of  carbon.  The  fluid  assumes  a 
blue  colour,  and  if  shaken,  a  part  of  the  iodine  is  taken  up  by  the  bisulphide 
of  carbon,  producing  a  violet  colour,  and  where  the  bisulphide  of  carbon 
touches  the  rest  of  the  fluid  a  dark-blue  ring  of  the  iodide  of  starch  gradually 
develops. 


§46.]  THE   DIFFERENT  ANTISEPTICS.  16^ 

According  to  Harnack,  this  last  test  is  the  most  delicate ;  but  all  these 
reactions  are  directly  dependent  upon  the  presence  of  iodine  in  the  urine  in 
the  form  of  an  alkaline  iodide  (iodide  of  sodium,  etc.).  He  claims  that 
iodine  derived  from  the  external  use  of  iodoform  occurs  in  the  urine  not  only 
as  an  alkaline  iodide,  but  also  as  a  compound  with  organic  substances,  and  in 
the  latter  state  does  not  give  the  above  reactions.  Harnack  noticed  in  two 
cases  that  the  test  for  iodine  in  the  urine  was  negative ;  but  if  the  urine  was 
evaporated  and  the  residue  burned,  the  ashes  gave  a  very  plain  iodine  re- 
action.    His  method  is  as  follows  : 

The  urine  is  rendered  alkaline  by  the  addition  of  sodium  somewhat  in 
excess,  and  evaporated  in  a  platinum  crucible  in  which  the  residue  is  then 
burned  by  heating  the  crucible  red-hot.  Th,e  carbonised  ash  is  then  re- 
peatedly treated  with  hot  water  and  the  resulting  extracts  are  filtered.  To 
the  filtrate  is  then  added  a  few  drops  of  dilute  starch  paste  and  fuming  nitric 
acid,  together  Avith  a  few  drops  of  bisulphide  of  carbon.  When  the  solution 
is  acidulated  with  dilute  sulphuric  acid  the  presence  of  iodine  is  indicated  by 
a  blue  colour ;  when  shaken,  the  bisulphide  of  carbon  lying  at  the  bottom 
takes  on  a  violet  tint,  and  just  above  it  there  forms  a  dark-blue  ring  of  the 
iodide  of  starch.  To  recognise  the  difference  between  the  intensity  of  the 
reaction  obtained  from  the  ash  and  from  the  uinne,  the  former  must  be 
mixed  with  a  volume  of  water  equal  to  the  amount  of  the  original  unevapo- 
rated  urine,  and  then  the  reaction  is  carried  out  with  equal  quantities  of  this 
mixture  and  of  urine. 

Substitutes  for  Iodoform. — The  following  preparations  have  been, 
recommended  as  substitutes  for  iodoform  :  lodoformin,  iodoformol, 
iodoformogen  (see  page  165),  iodol,  salubrol,  salol,  europhen  (contain- 
ing 28.1  per  cent,  iodine),  aristol  (a  combination  of  iodine  and  tbjmol), 
loretin  (a  non-poisonous,  yellowish  crystalline  powder),  xeroform  (tri- 
brom-phenol -bismuth),  salubrol  (tetrabrom -methyl  en -di-antipyrin), 
amyloform  (chemical  compound  of  formaldehyde  with  starch,  noso- 
phen  (eudoxin,  tetra-iodo-phenol-pbthalein),  sanoform  (diiodo-salicylic 
methyl-ester),  etc.  Aristol  has  no  odour  and  is  non-poisonous,  and  is 
particularly  useful  in  the  treatment  of  various  skin  diseases.  Pallin 
saw  a  case  of  iodol  poisoning  after  the  nse  of  five  grammes  of  this 
substance  in  a  sequestrotomy  of  the  clavicle.  Salol  should  be  given 
internally  with  caution,  on  account  of  the  phenol  it  contains ;  Hessel- 
bach  observed  a  death  follow  the  administration  of  eight  grammes  of 
this  drug,  which  parted  with  about  3.04  gi-ammes  of  carbolic  acid  in 
the  body. 

Dermatol  is  an  excellent  non-poisonous  substitute  for  iodoform, 
and  much  used  in  the  treatment  of  skin  diseases.  The  cases  of  poison- 
ing from  dermatol  which  have  been  reported  by  Weissenm idler  and 
others  were  probably  caused  by  the  use  of  an  impure  preparation 
(arsenic?).  Haegler  recommended  airol,  a  compound  of  dermatol 
with  iodine.     Among  the  newer  antiseptic  powders  diiodthioresorcin, 


170     THE  ANTISEPTIC  AND  ASEPTIC  PROTECTIVE  DRESSINGS. 

siilphaminol,  nosoplien,  and  sozoidol  are  particularly  well  spoken  of. 
The  latter  non-poisonous  powder  is  used  in  the  form  of  a  one-per-cent. 
emulsion  in  glycerine,  gum  arable,  and  water,  also  in  the  form  of  an 
ointment,  and  for  catarrhal  conditions,  etc. 

Of  the  remaining  antiseptic  substances,  of  which  there  are  a  great 
number  of  considerable  merit,  I  shall  briefly  mention  the  following : 

Orthoform  is  a  white,  iion-poisonous,  odourless,  and  tasteless  powder, 
wliicli,  oil  account  of  its  prolonged  aucesthetic  action  and  its  capability  of 
-diminishing  secretions,  is  used  a  good  deal  for  burns,  ulcers,  and  venereal 
sores,  and  internally  for  ulcer  of  the  stomach,  etc. 

Naphthaliu. — Xaphthalin  (CioHs)  was  isolated  from  coal  tar  bj^  Gardener 
in  1828.  It  forms  large,  shining,  colourless,  crystalline  i^lates  of  a  tarry 
odour  and  a  burning  taste.  It  is  insoluble  in  water,  readily  soluble  in  hot 
alcohol,  ether,  volatile  and  fixed  oils.     It  burns  with  a  bright,  sooty  flame. 

Naphthaliu  is  dusted  over  a  woviud  in  the  same  way  as  powdered  iodo- 
form. In  my  own  experience  I  have  found  naphthaliu  a  most  excellent 
disinfectant.  A  foul  wound  will  quickly  clean  up  aftei'  dusting  it  with 
naphthaliu,  and  the  process  of  granulation  is  accelerated.  Sometimes,  how- 
ever, its  use  is  accompanied  by  pain. 

Benzoic  Acid. — Benzoic  acid  ciystallises  in  the  form  of  thin  plates  or 
needles,  which  are  only  slightly  soluble  iu  cold  water  (1  to  500)  but  readily 
soluble  in  hot  water  (1  to  30),  and  in  alcohol,  ether,  and  concentrated  sul- 
phuric acid.  Benzoic  acid  is  usually  employed  in  .solution  in  the  strength  of 
1  to  200. 

Sulpho-carbolate  of  Zinc. — Bottini  (Pavia)  has  recommended  sulpho-car- 
bolate  of  zinc  as  an  antiseptic.  It  forms  large,  white,  transparent,  odourless, 
rhomboidal  crystals,  which  are  readily  soluble  in  distilled  water,  alcohol,  and 
other  liquids.  Bottini  considers  the  sulpho-carbolate  of  zinc  better  than  all 
other  similar  antiseptics.  It  has  the  gi'eat  advantage  of  being  absolutely 
nou-poisonous.     It  is  employed  in  two-  to  ten-per-cent.  solutions. 

Alcohol. — Dressings  of  alcohol  have  been  used  since  the  most  ancient 
times,  and  were  in  great  repute  even  in  Heister's  day.  In  France,  and  per- 
haps in  England,  this  liquid  finds  its  most  extensive  use.  Fifteen-  to  twenty,- 
per-cent.  solutions  have  been  used  for  washing  out  wounds  and  for  disin- 
fecting instruments,  sponges,  etc.  Salzwedel  recommends  a  dressing  of 
ninety-six  per  cent,  purified  alcohol  in  the  treatment  of  cellulitis,  abscess, 
lymphangitis,  felon,  and  furuncle.  His  dressing  consists  of  the  following 
three  layers  :  (1)  a  thick  layer  of  gauze  soaked  iu  alcohol,  (2)  dry  cotton,  and 
(.3)  perfoi'ated  rubber  tissue.  Other  surgeons  have  also  found  alcohol  dress- 
ings useful.  Accox'ding  to  Hack,  it  has  the  efPect  of  rendering  granulations 
which  have  been  treated  with  it  incapable  of  absorbing  anything. 

Terebene.— Terebeue  (CaoHie)  is  a  brownish  oily  fluid  with  a  pleasant, 
aromatic  odour,  insoluble  in  alcohol,  ether,  water,  etc.,  but  soluble  in  all  pro- 
portions in  oil.  It  is  much  used,  particularly  in  England,  for  the  treatment  of 
-wounds,  either  in  the  undiluted  form  for  badly  granulating,  foul,  gangrenous 
wounds,  or  diluted  with  equal  parts  of  oil  for  the  saturation  of  dressings,  or 
else  it  is  mixed  with  water  (30  to  500)  and  used  for  irrigation  purj)oses. 


§46.]  THE  DIFFERENT  ANTISEPTICS.  171 

Eucalyptus. — Eucalyptus  is  a  volatile  oil  having-  a  strong  antiseptic  ac- 
tion, and  is  made  from  the  leaves  of  the  myrtacea?,  a  tree  growing  in  Bel- 
gium, Italy,  and  the  south  of  France  (the  Eucalyptus  globulus).  It  has  been 
recently  recommended  by  Schultz  as  an  excellent  non-j)oisonous  antiseptic. 
The  commercial  article  is  very  valuable  in  quality,  and  Schultz  advises  that 
the  oil  be  .treated  with  soda  until  its  acid  reaction  becomes  neutralised,  and 
then  be  exposed  in  sunlight  to  the  action  of  the  oxygen- in  the  air,  which 
causes  the  oil  to  lose  its  pungent  odour  and  become  non-irritating  when  used 
in  dressings.  The  oil  of  eucalyptus  can  be  mixed  with  alcohol  and  water, 
0.2  to  0.3  per  cent.,  and  then  used  as  a  fluid  in  which  to  wring  out  com- 
presses. Lint  which  has  been  soaked  in  a  solution  of  one  i^art  oil  of  euca- 
lyptus and  ten  parts  olive  oil  can  be  used  for  applying  to  wounds. 

Iodine. — The  antiseptic  properties  of  iodine,  tincture  of  iodine,  the  solu- 
tion of  iodine  in  an  aqueous  iodide  of  potash  solution  and  of  iodine  vapour, 
have  been  proved  by  countless  experiments.  In  recent  times,  in  England 
and  America,  the  solution  of  iodine — i.  e.,  iodine  two  parts,  iodide  of  potas- 
sium three  parts,  and  water  forty-eight  parts,  has  been  used  for  dressings, 
lint  being  steeped  in  this  mixture.  The  combination  of  this  iodine  solution 
with  laudanum  is  also  highly  spoken  of.  For  cleansing  wounds,  Bryant 
recommends  iodine  water  (one  part  tincture  of  iodine  to  75  to  100  of  water). 

Trichloriodine. — Langenbuch  recommended  trichloriodine  (1  to  1,000- 
1,500)  as  practically  devoid  of  danger,  and  as  a  suitable  material  for  the  dis- 
infection of  the  instruments,  hands,  the  field  of  operation,  sponges,  etc.,  and 
he  tested  it  in  a  great  number  of  cases.  In  germicidal  power  it  stands  next 
to  bichloride  of  mercury  (Riedel). 

Creolin. — Jeyes,  its  discoverer  (1875),  Korttim,  Frohner,  and  others,  recom- 
mend creolin  in  a  one-  to  two-per-cent.  solution,  which,  according  to  Henle, 
is  a  mixture  of  soap,  oil  of  creolin,  phenol,  and  pyridin  ;  it  combines  the  use- 
ful properties  of  bichloride  of  mercury  and  iodoform  without  their  poisonous 
effects.  Creolin  is  an  oily,  dark-brown  fluid,  smelling  of  tar,  and  is  made  by 
the  dry  distillation  of  coal  tar,  forming  with  water  a  milky  emulsion  which 
has  a  threefold  more  powerful  action  than  carbolic  acid,  and  is  used  in  a 
one-  to  two-per-cent.  solution.  Esmarch  has  given  fifty  grammes  of  creolin 
to  animals  internally  without  causing  any  bad  effects.  Behring,  Baum- 
garten,  etc.,  maintain  that  creolin  has  no  such  germicidal  properties  as  car- 
bolic acid  or  bichloride  of  mercury,  and  that  it  is  more  poisonous  than  has 
been  hitherto  supposed.  In  severe  cases  of  creolin  poisoning— for  example, 
after  the  internal  administration  of  large  amounts— there  occur  loss  of  con- 
sciousness, albumen  and  blood  and  renal  epithelium  in  the  urine,  enlarge- 
ment of  the  liver,  and  jaundice  (van  Ackeren). 

Tricresol,  in  a  one-per-cent.  solution,  is  said  to  correspond  in  its  action  to 
a  three-per-cent.  carbolic  solution.  Cresolum  purum  liquef actum  is  used  by 
some  in  place  of  carbolic  acid.  Formalin  (formaldehyde)  has  been  used  a 
great  deal  of  late  for  the  sterilisation  of  the  hands,  the  field  of  operation,  etc. 

Peroxide  of  Hydrogen.— Peroxide  of  hydrogen  (two-  to  three-per-cent. 
solution)  is  rather  expensive,  and  on  account  of  its  unstable  character  it  is 
unsuited  for  an  antiseptic. 

Rotter's  Antiseptic  Solution.— Rotter  has  combined  a  great  number  of 
antiseptics  in  one  solution.     To  one  litre  of  water  are  added  bichloride  of  mer- 


172     THE  ANTISEPTIC  AND  ASEPTIC  PROTECTIVE  DRESSINGS. 

cury  0.05  gramme,  sodium  chloride  0.25  gramme,  carbolic  acid  2.0  grammes, 
cliloride  and  sulpho-carbolate  of  zinc,  each  5.0  grammes,  boric  acid  3.0 
grammes,  salicylic  acid  0.6  gramme,  thymol  0.1  gramme,  and  citric  acid  0.1 
gramme.  The  ingredients  of  this  solution  are  also  combined  in  tablet  form, 
and  called  "  Rotterin."  Rotter  also  left  out  of  this  solution  bichloride  of 
mercury  and  carbolic  acid,  and  considei's  that  the  remaining  ingredients  have 
a  stronger  antiseptic  action  than  one-tentli-per-cent.  solution  of  bichloride 
alone.  Beyer  has  demonstrated  that  all  these  different  antiseptics  combined 
in  the  one  solution  do  not  undergo  any  change. 

Aniline  Dyes. — Stilling  recommends  the  aniline  dyes  for  antiseptics  in  the 
form  of  an  aqueous  solution  of  (pyoktanin,  Merk.)  methyl  violet  (1  to  1,000), 
but  its  value  has  not  been  confirmed  by  others  (Carl,  Jaenicke,  Petersen,  etc.). 

Lysol.— Lysol  in  one  fourth-  to  two-per-cent.  aqueous  solution,  manufac- 
tured by  Schiilke  &  Mayer,  in  Hamburg,  is  an  excellent  and  relatively  non- 
poisonous  antiseptic,  and  is  recommended  by  Engler,  E.  Schmidt,  Gerlach, 
etc.,  and  has  been  much  used  in  operations.  On  account  of  its  cheapness 
and  its  non-poi§onous  character  lysol  is  very  well  adapted  for  disinfecting 
and  cleansing  purposes,  instead  of  carbolic  acid. 

Solveol. — Solveol  (Hammer,  A.  Hiller),  a  cresol  compound  (neutral  aque- 
ous solution  of  creosol)  in  0.5-per-cent.  solutions,  has  a  more  powerful  anti- 
septic action  than  five-per-cent.  carbolic  solutions,  and  it  is,  furthermore, 
comparatively  non-poisonous. 

IchthyoL — Ichthyol  is  extensively  used  in  the  treatment  of  erysipelas 
and  other  skin  diseases.  Latteux  commends  the  antiseptic  effect  of  five-  to 
ten-per-cent.  solutions  for  irrigating  purposes. 

AlunmoL — Alumnol  (Heinz,  Liebrecht)  is  a  white  powder  which  is  highly 
recommended  for  the  treatment  of  skin  diseases  and  gonorrhoea,  and  in  one- 
half-  to  two-per-cent.  solutions  for  the  disinfection  of  cavities,  abscesses, 
infected  wounds,  ulcers,  etc.  Cauterisation  with  a  ten-  to  thirty-per-cent. 
solution  is  useful  for  cleansing  ulcers. 

Tmuenol  has  been  recommended  by  Neisser  for  the  treatment  of  erosions, 
excavations,  ulcers,  eczema,  and  other  skin  diseases. 

Teucrin. — Mosetig-Moorhof  reports  good  results  from  injections  of  teu- 
crin  for  local  fungous  lesions.  It  is  an  extract  of  teucrium  scordium,  which 
has  a  marked  action  on  the  vasomotor  nerves. 

Preparations  of  Silver. — Silver  is  an  excellent  antiseptic,  and  Crede  has 
developed  a  method  of  treating  wounds  with  silver  preparations  which  is 
based  on  exact  bacteriological  experiments.  He  covers  sutured  and  open 
wounds  with  his  silver  gauze  and  dusts  itrol  (argentum  citricum)  over  punc- 
tured wounds.  The  silver  gauze  contains  metallic  silver  in  a  very  finely 
divided  form  ;  it  is  absolutely  non-irritating,  and  develops  an  antiseptic 
action  in  a  wound  as  soon  as  germs  make  their  appearance,  because  the  latter 
produce  lactic  acid  which  forms  lactate  of  silver,  a  strong  antiseptic.  Itrol 
and  actol  (argentum  lacticum)  are  used  in  solutions  of  1 :  4,000-8.000  for  irri- 
gation. As  actol  is  absolutely  non-poisonous.  Crede  uses  it  internally  in 
sepsis  and  pyaemia.  He  also  impregnates  silk,  catgut,  and  drainage  tubes 
with  silver.  The  stains  on  the  linen  produced  by  the  silver  salts  are  easily 
removed,  even  when  old,  by  placing  the  stained  linen  for  a  few  minutes  in  a 
solution  of  1  gramme  bichloride,  2,000  grammes  water,  and   25  grammes 


§47.]  THE  CHOICE   OP  AN  ANTISEPTIC.  1Y3 

sodium  chloride.  It  is  then  thoroughly  rinsed  off.  Crede  succeeded  in  pre- 
paring silver  that  is  soluble  in  water.  He  recommends  this  solution  of 
metallic  silver  (0.5-per-cent.  solution)  both  for  internal  use  and  for  subcu- 
taneous or  intravenous  injections.  He  also  uses  an  ointment  containing 
metallic  silver  for  inunctions,  in  cellulitis,  lymphangitis,  septic  intoxication, 
scarlet  fever,  diphtheria,  etc.  It  is  not  yet  possible  to  give  a  correct  opinion 
of  the  internal  antiseptic  values  of  silver,  as  the  number  of  observations  is 
too  small.  In  some  cases  I  have  seen  surprisingly  good  results,  and  in  others 
they  were  negative.     Unguentum  Crede  contains  fifteen  per  cent,  of  sil  ver. 

Other  Antiseptics. — There  are  still  to  be  mentioned  alum,  quinine,  chloral 
(one  to  four  per  cent,  in  water),  chloroform  water  (Salkowski),  chloride  of 
lime,  carbonate,  acetate,  and  chloride  of  lead,  acetic  acid,  permanganate  of 
potassium  (from  1 : 1,000-100),  camphor,  and  the  spirits  of  camphor,  glycerine, 
sugar,  sulphate  of  zinc,  oxide  of  zinc,  citric  acid,  trichlorphenol  (one-  to  ten- 
per-cent.  solution),  turpentine,  tar,  peroxide  of  hydrogen,  sulphuric  acid,  and 
the  sulphates  and  subsulphates  of  the  alkalies,  picric  acid,  resorcin,  balsam 
of  Peru,  styron  (one  per  cent.),  charcoal,  powdered  coffee,  naphthol  (soluble 
in  5,000  parts  of  water,  but  more  soluble  by  the  addition  of  alcohol),  tannic 
acid,  chromic  acid,  bichromate  of  potassiunt,  aseptol  (two-  to  ten-per-cent.), 
aseptic  acid  (five-  to  ten-per-cent.  solution),  etc. 

§  47.  Which  Antiseptics  and  which  Antiseptic  or  Aseptic  Dressings 
arie  the  Best? — Which  antiseptic  among  the  great  number  which  are 
recommended  is  the  most  powerful  and  at  the  same  time  the  best 
adapted  to  the  treatment  of  wounds  ?  My  own  experience  places  car- 
bolic acid  and  bichloride  of  mercury  at  the  head  of  the  list  for  cer- 
tainty in  action,  and  if  used  with  caution,  particularly  in  the  case  of 
children  and  cachectic  individuals,  they  are  also  devoid  of  danger. 
For  aseptic  operations  common  salt  solution  or  simply  sterilised  water 
may  be  used.  Among  the  other  antiseptics  the  ones  which  I  consider 
the  best  are  boric  acid,  acetate  of  aluminium,  creolin,  lysol,  salicylic 
acid,  iodoform,  oxide  of  zinc,  and  dermatol.  The  method  of  their 
application  has  been  sufficiently  described  above. 

Which  antiseptic  or  aseptic  material  is  the  best  for  dressings  ? 
Their  number  is  almost  without  limit,  and  the  choice,  as  we  have 
remarked,  is  more  or  less  a  matter  of  taste.  But  the  great  principles 
involved  remain  the  same,  namely,  that  the  operation  must  be  con- 
ducted with  the  strictest  attention  to  asepsis  and  that  the  arrest  of  the 
haemorrhage,  the  drainage,  and  the  suturing  of  the  wounds  should  all 
be  carried  out  with  the  greatest  care.  The  fate  of  the  patient  who 
has  been  operated  upon  depends  very  largely  upon  whether  the  oper- 
ation has  been  performed  aseptically  or  not.  The  dressing  that  is  put 
on  the  wound  has  no  longer  the  importance  that  was  at  one  time 
ascribed  to  it.  It  should  consist  of  freshly  sterilised  material  which 
has  good  absorptive  power  (gauze,  cotton,  moss,  wood   wool,  paper 


174     THE  ANTISEPTIC  AND  ASEPTIC  PROTECTIVE  DRESSINGS. 

woo],  etc.).  Moss,  wood  wool  or  excelsior,  jute,  etc.,  are  covered  witli 
sterilised  gauze  and  applied  in  the  shape  of  sterilised  pads  or  cushions. 
All  materials  used  for  dressings  should  be  sterilised  by  steam  at  a  tem- 
perature of  1(»0°-130°  C.  for  twenty  to  thirty  minutes  in  a  steam  ster- 
ilising apparatus.  Dressings  which  have  been  impregnated  with  anti- 
septics become  after  a  time  less  aseptic,  and,  furthermore,  produce 
irritation  of  the  skin  and  cause  an  eczema  (see  pages  3,  4).  My  own 
method  of  applying  a  dressing  is  very  simple,  and  is  ordinarily  done  as 
follows :  The  wound,  or  the  suture  line,  is  covered  with  several  la^-ers 
of  sterilised  gauze  or  iodoform  gauze ;  over  this  is  placed  cotton  which 
has  been  sterilised  by  steam  at  a  temperature  of  100°  C.  (212°  F.). 
The  less  the  wound  is  irritated  by  antiseptics,  or,  in  other  words,  the 
dryer  the  operation,  so  much  the  less  is  the  subsequent  secretion  from 
the  wound,  and  there  is  consequently  less  need  of  dressings  having 
great  absorptive  powers  like  moss  pulp,  wood  wool,  etc. ;  gauze  covered 
with  absorbent  cotton  or  jute  cushions  will  be  all  that  is  required. 

To  favour  the  drying  of  the  secretion  from  the  wound  within  the 
dressings  the  gutta-percha  or  mackintosh  should  be  avoided,  except  in 
the  case  of  young  children,  w^hen  some  water-tight  substance  should  be 
employed  to  prevent  the  dressings  from  becoming  soiled  by  urine, 
faeces,  etc.  In  small  children  I  often  dispense  with  the  dressing.  All 
the  dry  antiseptic  dressings  are  much  better  than  those  of  the  wet 
antiseptic,  occlusive  variety,  as  the  latter  are  apt  to  occasion  an  eczema 
frequently  lasting  a  good  while,  and  increase  the  danger  of  poisoning, 
particularly  from  carbolic  acid  and  bichloride  of  mercury.  But,  as  we 
shall  see,  wet  dressings  are  sometimes  most  excellent  for  contused  and 
suppurating  wounds.  I  never  apply  antiseptic  dusting  powders,  Hke 
iodoform,  bismuth,  salicylic  or  boric  acids,  to  a  wound  which  has 
been  closed  by  sutures.  This  powder  dressing  is  chiefly  suited  for 
wounds  which  have  not  been  closed  by  sutures  and  for  those  which 
are  granulating  or  suppurating.  Open  wounds  are  often  packed  with 
sterile  or  iodoform  gauze  and  then  closed  by  secondary  sutures  from 
two  to  four  days  after  removal  of  the  packing.  I  attach  great  impor- 
tance to  the  use  of  a  moderate  amount  of  pressure  upon  the  wound, 
particularly  after  the  extirpation  of  tumours.  For  this  purpose  the 
gauze  is  folded  up  so  as  to  make  a  pad.  Antiseptic  sponges  have  also 
been  employed  with  good  results  for  exerting  pressure  on  wounds. 
For  an  ointment  I  prefer  boric  acid  or  plain  vaseline.  For  covering 
the  suture  line  and  touching  up  superficial  erosions,  granulations,  etc., 
I  often  make  use  of  zinc  glue  or  bismuth  paste  (bismuth  stirred  up  in 
a  little  bichloridej.  If  it  is  necessary  to  disinfect  an  already  infected 
wound,  I  use  solutions  of  bichloride  of  mercury  (1  to  1,000-5,000). 


48.] 


THE  CHANGING  OF  AN  ANTISEPTIC  DRESSING. 


1T5 


The  antiseptic  and  aseptic  dressings  should  be  as  large  as  conven- 
ient, thongh  I  do  not  consider  this  now  of  as  much  importance  as  I 
used  to.  Aseptic  operation  wounds,  for  example,  after  a  laparotomy, 
may  simply  be  covered  with  collodion  or  bismuth  paste.  For  apply- 
ing the  dressing  the  patient  should  be  placed  in  the  most  suitable  posi- 
tion. For  bandaging  the  head,  shoulder,  and  thorax  the  patient  should 
be  made  to  assume  a  sitting  posture,  while  for  the  abdominal  region 
one  or  more  cushioned  props  (Fig.  142)  are  placed  under  the  patient 
while  the  legs  are  held  by  an  assistant.     Splints  of  wood,  sheet  metal^ 


Fig.  142. — Support  for  the  pelvis 
(Volkmannj. 


Fig.  148.- 


•Aseptic  dressing  for  the 
scalp. 


Fig.  144.- 


-Aseptic  occlusive  dressing  for  the  head, 
neck,  and  chest. 


plaster  of  Paris,  or  wire,  etc.,  serve  to  immobilise  an  extremity  (see  § 
53).  For  less  serious  cases  thin,  pliable  wooden  hoops  are  exceedingly 
useful.  One  of  the  great  advantages  of  the  antiseptic  and  aseptic 
methods  of  treating  wounds  lies  in  the  fact  that  the  dressing  requires 
much  less  frequent  renewal  than  formerly,  when  the  unsatisfactory 
occlusive  dressing  was  employed. 

Figs.  143  and  144  illustrate  two  methods  of  applying  an  aseptic 
dressing  to  the  skull  and  the  head,  neck,  and  chest.  The  particulars 
are  given  in  §  .50. 

§  48.  The  Changing  of  an  Antiseptic  or  an  Aseptic  Dressing. — When 
shall  an  aseptic  dressing  be  changed  ?  In  the  first  place,  the  nature  of 
the  case  and  the  kind  of  operation  or  injury  must  be  considered. 

In  general  it  has  been  my  experience  that  a  change  of  the  dressing 
is  called  for  under  the  following  conditions : 


176      THE  ANTISEPTIC   AND  ASEPTIC   PROTECTIVE   DRESSINGS. 

1.  When  tlie  tem-perature  rises  above  38.5°  C.  (I0l.3°  F.). 

2.  When  the  dressing  becomes  soiled  from  without — for  example, 
by  urine  or  other  excretory  matter. 

3.  When  the  patient  is  snifering  severe  pain. 

4.  When  the  dressing  becomes  displaced  or  loosened,  or  when  the 
secretion  from  the  wound  has  saturated  tlie  dressing. 

Whenever  fever  occurs — and  I  make  a  regular  practice  of  con- 
sidering any  rise  of  temperature  above  38.5°  C.  (101,3°  F.)  under  this 
heading — I  change  the  dressing,  and  am  pretty  sure  to  find  that  there 
is  .  either  some  slight  disturbance  in  the  wound,  a  retention  of  the 
secretion,  or  a  stitch  which  is  too  tight,  etc.  As  a  general  thing,  in 
my  own  operations  I  have  very  seldom  observed  any  rise  in  tempera- 
ture above  38.-l°  C.  (101°  F.).  Other  surgeons  have  noticed  a  rise 
of  temperature  of  several  degrees  during  the  healing  of  a  perfectly 
aseptic  wound.  Volkmann  and  Genzmer,  especially,  have  made  in- 
vestigations upon  this  fever  and  have  called  it  the  "  aseptic-wound 
fever."  I  have  very  seldom  seen  the  aseptic-wound  fever,  and  when 
a  rise  in  temperature  does  occur  while  the  healing  process  is  going  on 
it  will  usually  be  found  to  take  its  origin  from  some  perceptible  ab- 
normity in  the  wound.  Opinions  vary  as  to  the  cause  of  this  aseptic- 
wound  fever.  Yolkraann  and  Genzmer  consider  it  an  absorption  fever 
produced  by  the  entrance  into  the  general  system  of  the  relatively 
homologous  products  of  metabolism  and  disintegration  which  are 
formed  in  every  wound.  Sonnenburg  and  Kiister  believe  that  aseptic- 
wound  fever  is  caused  by  carbolic-acid  poisoning.  Both  of  these  views 
are  of  use  in  explaining  the  phenomena.  My  own  view  of  the  aseptic- 
wound  fever  leads  me  to  believe  that  it  is  caused  by  the  absorption  of 
lymph  and  the  fibrin  ferment  from  the  blood  lying  in  the  wound. 
This  fibrin  ferment  is  formed  the  more  abundantly  the  more  the  wound 
has  been  irritated  by  carbolic  acid  or  other  strong  antiseptic  solutions. 
I  believe  I  am  not  mistaken  in  aflirming  that  all  surgeons  who  make 
free  use  of  solutions  of  bichloride,  carbolic,  or  other  irritating  antisep- 
tics in  their  treatment  of  wounds,  will  frequently  notice  aseptic  rises 
in  temperature,  while  those  surgeons  who  are  cautious  in  their  use  of 
antiseptics,  and  prefer  asepsis  to  antisepsis,  will  only  observe  this  phe- 
nomenon in  a  few  exceptional  cases.  Many  surgeons — Neuber,  for 
instance — have  recommended  that  the  dressing  be  allowed  to  remain 
undisturbed  in  such  instances  of  aseptic  fever,  claiming  that  a  change 
of  dressing  only  creates  further  disturbance  in  the  wound,  and  is  conse- 
quently harmful.  I  cannot  agree  to  this  statement,  though  I  seldom 
have  to  do  with  fever  following  an  operation.  If  it  does  occur,  I 
always  change  the  dressing  as  a  matter  of  course,  if  the  temperature 


§48.]  THE  CHANGING  OF   AN  ANTISEPTIC  DRESSING.  1^7 

rises  above  38.5°  C.  (101.3  F.),  and  I  usually  find,  as  I  have  said,  some 
flight  variation  from  the  normal  in  the  healing  process.  I  prefer  to 
change  the  dressing  as  infrequently  as  possible,  and  I  am  particularly 
careful  to  avoid  irritating  the  wound  by  excessive  irrigation,  washing 
out,  etc.     It  can  only  do  harm. 

From  what  has  been  said  so  far,  we  can  readily  understand  the 
importance  of  ascertaining  a  patient's  temperature  in  the  morning  and 
evening,  or,  in  more  important  cases,  three  to  four  times  a  day,  or 
even  every  two  hours,  and  it  is  best  taken  in  the  rectum.  I  prefer,  if 
there  is  fever,  to  change  the  dressing  too  frequently  rather  than  allow 
one  to  remain  too  long.  If  the  discharge  should  soak  through  the 
■dressings,  they  can  still  be  left  undisturbed,  if  only  the  external  layers 
remain  dry  and  no  fever  is  present.  Additional  layers  of  dressing 
may  be  placed  on  the  outside,  if  necessary. 

My  rules  for  changing  an  antiseptic  dressing  are  as  follows  :  If  the 
wound  is  large,  and  there  is  considerable  discharge,  I  change  the  first 
dressing  after  the  expiration  of  twenty-four  to  thirty-six  hours,  even 
though  there  is  no  rise  in  temperature ;  or  I  allow  the  first  antiseptic 
dressing  to  remain  undisturbed  till  the  end  of  the  third  to  the  fourth 
to  the  eighth  day,  according  to  the  nature  of  the  case.  Drains  are 
removed  at  the  end  of  the  first  twenty-four  hours,  or  on  the  second  to 
the  third  day,  the  stitches  generally  on  the  third  to  the  fifth  day. 
After  a  laparotomy  which  runs  a  normal  course  without  reaction,  I 
change  the  first  dressing  on  the  eighth  to  the  twelfth  day,  according  to 
the  size  of  the  abdominal  wound,  and  at  the  same  time  I  remove  the 
stitches,  though  if  the  wound  is  under  considerable  tension  a  stitch 
here  and  there  is  left  in  place  for  a  little  while  longer. 

An  aseptic  dressing  should  he  changed  only  with  the  strictest  atten- 
tion to  the  rules  of  antisepsis^  and  everything  which  is  required  for  the 
dressing,  particularly  the  gauze,  bandages,  etc.,  is  to  be  prepared  in 
advance  in  the  proper  manner.     The 
instruments,  such  as  scissors,  probes, 
forceps,  etc.,  should  be  boiled  in  a 
one-per-cent.  soda  solution  and  placed 
in  a  sterile  soda  or  salt  solution ;  the 
sponges  or  gauze  pads  should  he  in  -r.     , ,  -    t>    j 

^        ^  o  J.  ^  ^  jj(j_  X43_ — Bandage  scissors. 

a  one-tenth-per-cent.  solution  of  bi- 
chloride or  in  salt  solution.  The  hands  are  to  be  disinfected  with  the 
greatest  care  (see  page  10).  The  dressing  is  then  slit  up  with  strong 
bandage  scissors  (Fig.  145),  or  the  bandage  is  unwound,  and  after  it 
has  been  thoroughly  washed,  disinfected,  and  sterilised  by  steam  at 
100°  C,  it  may  be  used  again  as  a  non- antiseptic  bandage ;  but  it  is 
13 


178     THE  ANTISEPTIC  AND  ASEPTIC  PROTECTIVE  DRESSINGS. 

a  better  plan  to  burn  all  dressings  immediately  after  they  have  been 
taken  off.     I  never  use  the  carbolic  spray  now. 

After  removing  the  bandages  and  su})erlic'ial  portions  of  the  dress- 
ing, the  hands  are  again  disinfected,  and  then  the  portion  of  the  dress- 
ing lying  in  contact  with  the  wound  is  removed  as  carefully  as  possi- 
ble. If  it  adheres  to  the  skin  or  to  the  wound,  it  should  be  softened 
by  squeezing  out  upon  it  a  few  drops  of  the  antiseptic  solution  or 
sterile  salt  solution.  The  wound  is  then  examined  by  pressing  hei'e 
and  there  very  lightly  with  the  index  and  middle  lingers  to  ascertain 
whether  there  is  any  retention  of  the  secretion,  and  finally  the  drains, 
stitches,  etc.,  are  removed.  If  the  healing  process  is  progressing  nor- 
mally in  every  respect,  there  should  be  no  syringing  out  or  washing 
off  of  the  wound,  and  all  that  is  necessary  is  simply  the  application  of 
a  fresh  dressing.  The  forcing  of  antiseptic  solutions  through  the 
drainage  tubes  is  particularly  to  be  avoided,  as  it  always  does  harm,  and 
I  never  indulge  in  this  practice  except  when  suppuration  is  present, 
and  then  only  rarely.  If  the  drains  become  occluded  by  blood-clots 
and  are  to  remain  in  the  wound,  they  should  be  made  pervious  by 
passing  a  probe  through  them  ;  or,  better  still,  they  should  be  taken  out 
of  the  wound,  washed  in  a  three-per-cent.  solution  of  carbolic  or  1  to 
1,000  bichloride,  and  finally  reinserted  with  a  safety  pin  attached  to 
them  to  prevent  them  from  slipping  into  the  wound,  or  else  entii-ely 
new  drainage  tubes  may  be  employed.  Very  often  a  stitch  which  is 
cutting  into  the  tissues  or  is  drawn  too  tight  must  be  removed  at  the 
end  of  twenty-four  to  thirty-six  hours.  The  presence  of  swelHng  and 
redness  indicates  a  retention  of  the  secretion,  which  should  then  be  let 
out  by  one  or  more  incisions  with  the  knife,  with  or  without  subse- 
quent drainage.  If  there  is  an  appreciable  amount  of  suppuration  it 
may  be  necessary  in  some  cases  to  change  the  dressing  every  dav  for 
a  time,  or  to  substitute  for  the  antiseptic  occlusive  dressing  some  other 
simpler  kind.  Should  erysipelas  occur,  the  employment  of  ichthyol  is 
to  be  recommended,  and  the  antiseptic  occlusive  dressing  can  be  main- 
tained. 

Even  when  the  wound  remains  uninterruptedly  aseptic,  bacteria  are 
commonly  found  in  the  antiseptic  or  aseptic  dressings.  These  bacteria 
belong  chiefly  to  the  non-pathogenic  species  of  skin  coccus,  and  do  not 
interfere  with  the  normal  process  of  healing.  If  the  Staj)liylococGtis 
pyogenes  cmreus  and  the  Streptococcus  pyogenes  are  found,  there  will 
probably  be  a  disturbance  in  the  wound,  but  the  presence  of  the  Stcqjhy- 
loGOGCUs  pyogenes  albus  only  exceptionally  causes  an  infection  of  the 
wound  (Tavel,  O.  Lang,  A.  Flach).  Dressings  which  have  been  allowed 
to  remain  in  place  a  long  time  will  give  off  a  bad  odour  not  unlike  old 


§48.]  THE  CHANGING  OF  AN  ANTISEPTIC   DRESSING.  179 

cheese,  caused  ordinarily  by  tlie  decomposition  of  sweat  and  sebaceous 
matter.  Not  infrequently  there  will  be  found  an  eczema,  especially  if 
wet  carbolic  or  bichloride  dressings  have  been  used,  and  this  is  best 
treated  by  the  application  of  vaseline  or  the  ungt.  lithargyr.  Hebrse,* 
and  by  dusting  it  over  with  bismuth  and  starch  (1  to  5-10  parts),  or 
oxide  of  zinc  and  starch  (1  to  5-10  parts),  or  by  applying  Lassar's 
paste  (oxide  of  zinc  and  powdered  starch  aa  10  parts,  salicylic  acid  1 
part,  vaseline  20  parts).  Such  eczemas  can  be  best  avoided  by  the  use 
of  simple,  sterilised,  dry  dressing  materials. 

Eczema  of  the  Surgeon's  Hands  has  become  less  common  since  the  intro- 
duction of  asepsis,  but  it  does  occur  in  those  predisposed  to  it,  and  not  always 
at  the  beginning  of  their  surgical  career.  It  is  a  good  plan  for  such  persons, 
after  sterilisation  of  the  hands,  to  anoint  them  while  still  wet  with  a  sterile 
greasy  material  (e.  g.,  olive  oil,  glycerine,  lanolin,  and  vaseline,  equal  parts, 
into  two  per  cent,  resorcin).  Eczema  is  treated  in  the  same  way.  Lassar 
recommends  the  use  of  tar  oil  with  alcohol  at  night.  The  hands  are  then 
washed  half  an  hour  later  with  soap  and  water,  and  then  covered  overnight 
with  two  per  cent,  salicylic  paste  or  zinc-oil  paste  (60  parts  zinc  oxide,  40 
parts  olive  oil).  Before  applying  the  tar  the  following  paste  can  be  used 
(Lassar)  :  ^-naphthol  10,  sulph.  subl.  40,  sapon.  virid.  and  vaseline  aa  20 
parts.  Then  ten  to  fifteen  minutes  later  twenty-five  per  cent,  chrysarobin  in 
lanolin  is  applied,  and  in  ten  to  fifteen  minutes  more  the  tar.  Rotter  recom- 
mends for  moist  eczema,  formalin  0.25-0.5,  zinc  oxide  and  talcum  aa  25  parts, 
vaseline  50  parts.  It  is  sometimes  necessary  to  stop  surgical  work  for  a 
time.  The  action  of  the  different  remedies  is  very  variable.  Sometimes  the 
best  remedies  are  used  in  vain,  and  then  suddenly  one  may  be  helped  by 
simply  using  hot  water,  and  another  by  cold  water  or  an  ice  bag,  painting 
with  egg  albumen,  etc. 

If  the  wound  has  healed  there  is  generally  no  further  need  of  any 
dressing.  In  other  cases  it  may  be  necessary  to  cover  granulating  areas 
or  drainage  holes  with  some  ointment  like  boric-acid  ointment,  or  by 
sticking  plaster,  iodoform  collodion,  or  with  iodoform,  zinc  oxide,  or 
bismuth  powder,  or  with  a  piece  of  simple  dry  gauze  or  cotton.  Bis- 
muth-bichloride paste,  made  by  simply  mixing  bismuth  with  a  little 
bichloride  solution,  forms  an  excellent,  rapidly  drying  scab,  and  I  use 
it  a  good  deal  in  place  of  adhesive  plaster.  I  very  often  allow  an 
aseptic  material  which  has  become  dry  to  remain  on  the  wound  like  a 
scab,  with  or  without  a  protecting  bandage.  After  a  time  the  aseptic 
scab  drops  off  and  the  wound  is  found  to  be  healed. 

*  Unguentum  diachylon. 


CHAPTER  II. 

OTHER    METHODS    OF    TREATING    WOUNDS. 

The  old-fashioned  protective  dressing. — Open  method  of  treating  wounds. — Healing 
beneath  a  scab. — Antiseptic  bathing. — Immersion. — The  use  of  warm  baths. — 
Cataplasms. — Poultices. — Cold. — Ice. — Leiter's  cooling  apparatus. — Adhesive  sub- 
stances (sticking  plaster,  gauze  adhesive  plaster,  English  plaster,  collodion,  pho- 
tosylin,  trauraaticin.  gummi  lacca?). — Ointments. 

§  49.  Other  Dressings  for  Wounds. — The  old-fasliioned  protective 
dressings  of  sticking  plaster,  charpie,  ointments,  etc.,  are  no  longer 
used  at  the  present  day,  and  after  operations  we  now  cover  the  wound, 
without  exception,  with  antiseptic  or  aseptic  dressings,  though  in  the 
case  of  small  fresh  wounds,  or  those  which  are  granulating,  we  occa- 
sionally employ  adhesive  plaster,  collodion,  iodoform  collodion,  and 
antiseptic  salves,  boric-acid  ointment,  for  example. 

Open  Method  of  treating  Wounds. — The  open  method  of  treating 
wounds  is  the  simplest  one  of  all.  Small  superficial  wounds  are  now 
allowed  to  go  without  any  dressing,  especially  when  the  blood  and 
secretion  from  the  wound  becomes  dried  and  thus  forms  a  protecting 
crust  beneath  which  the  wound  heals. 

Healing  beneath  a  Scab. — The  healing  under  a  scab,  which  occurs 
in  small  wounds,  has  been  made  the  basis  of  a  separate  method  of  treat- 
ment, in  which  an  attempt  is  made  to  form  a  scab  artificially  over 
wounds  having  an  abundant  secretion  by  the  application  of  dry  sub- 
stances, such  as  tinder  and  various  kinds  of  powders,  or  a  dry  eschar  is 
made  by  some  strong  caustic,  like  nitrate  of  silver,  liq.  fern  sesquichlor., 
the  hot  iron,  etc.  All  these  different  ways  of  accomplishing  the  same 
result,  if  carried  out  with  no  antiseptic  precautions,  even  though  the 
wound  be  small,  are  not  devoid  of  danger.  But  the  modern  surgeon 
never  fails  to  treat  every  wound,  including  the  very  smallest,  upon  anti- 
septic principles,  because  we  know  that  even  the  most  insignificant  lesion 
in  the  skin,  under  certain  conditions,  may  cause  a  septic  cellulitis  or  an 
erysipelas  which  can  prove  fatal.  On  the  other  hand,  Schede's  method 
of  treating  wounds  by  permitting  a  moist  aseptic  blood-clot  to  remain 
(see  page  109)  is  to  be  looked  upon  as  a  real  advance  in  this  branch  of 
surgery.  As  above  stated,  it  is  an  excellent  plan  to  permit  the  dried 
180 


49.] 


OTHER  DRESSINGS   FOR  WOUNDS. 


181 


dressings  to  remain  upon  the  wound  like  a  dry  aseptic  scab,  until  they 
come  away  of  their  own  accord  when  the  wound  has  healed. 

This  open  method  of  treating  wounds  yielded  relatively  excellent  results 
in  the  preantiseptic  days  of  surgery,  even  when  used  for  large  wounds,  such 
as  amputations,  disarticulations,  compound  fractures,  etc.,  and  was  practised 
till  supplanted  by  the  antiseptic  dressing. 

In  the  open  method  of  treatment  the  wound  was  not  provided  with  any 
dressing,  but  left  entirely  exposed,  or  only  lightly  covered  with  antiseptic 
compresses.  It  was  not  closed  with  sutures  until  later  on,  when  a  few  coap- 
tation sutures  were  used.  In  this  way  the  escape  of  the  secretion  from  the 
wound  was  favoured.  If  the  wound  was  situated  on  an  extremity,  the  latter 
was  placed  in  a  proper  position  to  facilitate  the  escape  of  the  discharges, 
which  were  received  in  a  vessel  or  bowl  placed  beneath.  The  crusts  which 
formed  in  the  wound,  from  dried  blood  or  secretions,  were  softened  and 
removed  by  means  of  antiseptic  solutions  or  by  carbolised  oil.  The  principal 
advantages  in  the  treatment  of  a  wound  by  the  open  method  were  a  ready 
escape  of  the  secretions,  complete  rest  which  was  undisturbed  by  change  of 
dressings,  and  finally  absence  of  pressure.  It  had  the  disad- 
vantage that  wounds  healed  slowly  and  only  after  suppuration. 

In  cases  where  the  antiseptic  occlusive  dressing  is  no 
longer  advisable  on  account  of  suppuration,  or  a  threaten- 
ing systemic  infection,  when  it  may  even  become  danger- 
ous from  the  pressure 
it    exerts,   the    open 
method    of    treating 
wounds,  particularly 
in  conjunction   with 
continuous  antiseptic 
irrigation,  is  now  in 
very  general  use,  and 
is     an  .  exceedingly 
valuable    means    of 
handling  these  cases. 

Continuous  Irriga- 
tion.—  For  continu- 
ous antiseptic  bath- 
ing of  a  wound,  or,  in 
other  words,  for  con- 
tinuous irrigation, 
such  antiseptic  solu-  "    --      -*' 

tions  should  be  used  as  involve  no  danger  to  the  patient  from  their 
absorption  and  produce  no  symptoms  of  poisonhag.  Of  these,  the  best 
are  three-tenths-per-cent.  solutions  of  salicylic  acid ;  the  boro-salicyhc 
solution  (1  part  of  salicylic  acid,  6  of  borax,  and  500  of  water)  ;  or  solu- 


FiG.  146. — Position  of  the  upper  extremity 
during  permanent  antiseptic  irrigation. 


182 


OTHER  METHODS  OF  TREATING  WOUNDS. 


tious  of  one  tenth  per  cent,  thymol,  four  per  cent,  boric  acid,  one  lialf 
to  one  per  cent,  acetate  of  aluminium,  or,  what  is  the  best  solution  of 
all,  viz.,  Burow's  (described  on  page  162),  consisting 
of  ten  per  cent,  subsulphate  of  sodium,  one  tenth  per 
cent,  permanganate  of  potassium,  lysol,  etc.  The 
wound  is  covei'ed  with  a  light  gauze  compress.  The 
patient  is  made  to  assume  a  suitable  position,  and 
protected  by  means  of  water-tight  coverings  and  also 
by  properly  regulating  the  overflow  of  the  irrigation 
fluid.  The  solution  is  made  to  drip  from  an  Es- 
march  irrigator  placed  in  some  elevated  spot,  or 
from  an  improvised  irrigator,  such  as  an  inverted 
champagne  bottle  from  which  the  bottom  has  been 
jDartly  removed  (Fig.  117),  or  the  excellent  apparatus 
of  Starcke  may  be  used  (Fig.  148).  Fig.  146  illus- 
trates the  proper  position  for  the  upper  extremity 
when  continuous  antiseptic  irrigation  is  employed. 
Starcke's  apparatus  consists  of  a  vessel  for  holding 
fluid  which  is  connected  by  a  rubber  tube  T^-ith  a 
lead  or  glass  pipe ;  this  is  fitted  with  numerous  out- 
lets also  connected  with  rubber  tubes  which  can  be 
opened  or  closed  by  stopcocks  or  clamps,  and  by 
means  of  vrires  in  their  interior  can  be  bent  and 
turned  in  any  desired  direction.  The  lead  or  glass  pipe  is  suspended 
from  some  beam  or  support  by  a  couple  of  strings. 

If  Esmarch's  irrigator  or  the  inverted  champagne  bottle  are  used 
as  in  Fig.  147,  the  fluid  is  made  to  escape  in  drops  or  in  any  required 
amount  by  means  of  a  stopcock  placed  at 
the  point  of  insertion  of  the  rubber  tube. 
If  the  tube  is  not  fitted  with  one,  the  out- 
flow of  fluid  can  be  regulated  by  a  clamp, 
or  a  piece  of  cotton,  or  a  few  strands  of 
jute  stuffed  into  the  lumen  of  the  tube,  or 
by  a  straw,  etc. 

Immersion. — Immersion,  or  bathing  of 
the  whole  body,  or  separate  portions  of  it 
which  have  sustained  an  injury,  is  in  many 
cases  indispensable.     The  continuous  im- 
mersion of  a  patient's  whole  body  in  a  warm  bath  day  and  night  is 
adapted  especially  for  gangrene,  extensive  burns,  cellulitis,  bedsores, 
urinary  and  faecal  fistulae,  and  for  the  after-treatment  of  operations 
on  the  rectum,  bladder,  urethra,  etc.     The  bath  tub  is  usually  made  to 


Fig.  147. — Improvised 
apparatus  ( irriarator) 
for  the  irrigation  of 
a  -wound. 


Fig.  148. — Starcke's  apparatas  for 
the  irrigation  of  a  wound. 


f  49.]  OTHER   DRESSINGS   FOR   WOUNDS.  183 

contain  a  framework  of  wood  or  metal  fitted  with  slats  and  a  movable 
headpiece  which  can  be  raised  or  lowered.  Covers  are  laid  over  the 
frame  and  an  air  cushion  on  the  headpiece,  and  thus  the  patient  is 
made  very  comfoi'table.  The  patient  can  be  placed  on  an  ordinary 
sheet  instead  of  a  frame,  and  in  this  way  can  be  raised  or  lowered  in 
the  tub.  The  temperature  of  the  water  must  not  be  allowed  to  become 
too  cool,  and  it  is  best  to  regulate  it  according  to  the  wishes  of  the 
patient,  and  therefore  it  is  a  good  plan  for  him  to  be  able  to  regulate 
the  temperature  of  the  bath  himself  by  turning  on  or  letting  out  the 
"water.  The  temperature  of  the  water  must  usually  be  maintained  at 
S7°  to  38°  C.  (98.6°  to  100.4°  F.),  and  perhaps  more,  and  of  course  the 
patient,  while  asleep,  should  be  watched  very  carefully  by  a  nurse. 

Influence  of  a  Continuous  Bath  on  a  Wound. — The  influence  of  pro- 
longed baths  of  this  kind  upon  a  wound  is  in  general  very  favourable. 
The  granulations  usually  swell  considerably,  and  it  occasionally  hap- 
peHS  for  this  reason  that  the  escape  of  the  discharges  is  rendered  dif- 
ficult, causing  retention  and  burrowing  of  pus  and  phlegmonous  in- 
flammations. The  wounds  should  hence  have  thorough  drainage. 
]^evertheless,  the  freely  granulating  surface  is  apt  to  become  covered 
with  skin  very  rapidly,  and  the  parts  surrounding  the  wound  become 
soft  and  yielding.  For  stimulating  the  growth  of  the  granulations. 
Irritant  substances,  like  spirits  of  camphor,  etc.,  have  been  added  to 
the  bath,  or  the  wounds  have  been  dressed  with  them.  If  the  bath 
becomes  too  cold  there  is  a  possibility  of  necrosis  taking  place  here 
and  there  in  the  skin  ;  and  care  should  be  taken  in  subjecting  old 
people  to  prolonged  baths  on  account  of  the  danger  of  pulmonary, 
cardiac,  or  cerebral  disturbances.  In  extensive  fresh  burns  also  baths 
should  be  used  cautiously,  as  the  warm  water  lowers  the  vascular  tone, 
and  in  this  way  cardiac  paralysis  may  result.  The  bath  is  vei-y  much 
to  be  recommended  during  the  stage  of  suppuration. 

The  use  of  baths  for  separate  portions  of  the  body  which  have  been 
injured  needs  no  further  description. 

Cataplasms.— Warm  poultices,  either  dry  or  wet,  were  much  used  in  the 
treatment  of  wounds  during  the  preantiseptic  days.  Fomentum,  a  hot,  wet 
application,  or  a  fomentation  as  it  is  called,  is  derived  from  foveo,  to  warm. 
Cataplasm,  or  poultice,  comes  from  the  G-reek  word  KaraTrXdacrQ),  to  lay  on. 
Cataplasms  or  poultices  are  made  of  boiled  linseed  meal,  gi'oats,  etc.,  which 
are  inclosed  in  gauze  or  linen  cloth  before  applying.  At  present  cataplasms 
are  not  considered  proper  for  the  treatment  of  wounds,  and  we  only  use 
them  when  we  desire  to  promote  suppuration  in  tissues  which  are  infiltrated 
with  inflammatory  matter.  The  preparation  of  poultices  is  very  tedious. 
The  hot  poultice  is  renewed  by  warming  the  wet. cushion  upon  a  hot  plate, 
or  in  vessels  made  for  the  purpose  with  double  walls  between  which  the 


184  OTHER  METHODS  OP  TREATING  WOUNDS. 

water  is  placed  to  supply  the  moisture,  and  the  vessel  is  then  heated  over  a 
gas  or  spirit-lamp  flame.  For  doing  away  with  this  slow  process  there  have 
recently  been  invented  artificial  cataplasms  about  the  weight  of  thin  paste- 
boai-d.  These  are  soaked  in  hot  water  and  applied  to  the  diseased  portion  of 
the  body  and  covered  over  with  some  Avater-tight  substance  and  then  with 
cotton.  They  afterward  swell  and  assume  a  pulpj*  consistence.  A  mustard 
Ijaper  is  also  manufactured  which  has  a  very  irritating  effect  upon  the  skin. 
In  place  of  cataplasms  a  Ijot-air  apparatus  and  the  hot-water  coil  have  been 
used  a  good  deal  of  late.  This  local  application  of  heat  is  particularly  useful 
in  chronic  joint  diseases,  rheumatism,  etc. 

Antiseptic  Wet  Dressings. — The  application  to  wounds  of  wet  anti- 
septic dressings  of  mull,  gauze,  lint,  linen,  etc.,  in  a  cold  or  hot  form  is 
even  at  the  present  time  much  used  in  the  treatment  of  contused,  sup- 
purating, and  granulating  wounds.  Wet  dressings  of  one  per  cent, 
acetate  of  aluminium  and  lead  water  are  used  a  great  deal,  and  are  pre- 
ferred to  dressings  containing  carbolic  acid.  The  latter  is  sometimes 
used  too  strong  by  the  laity,  and  also  changed  too  frequently.  I  have 
repeatedly  seen  gangrene  of  the  tips  of  the  fingers  caused  by  carbolic 
acid  applied  in  this  form.  A  distinct  warning  should  be  given  against 
the  employment  of  carbolic  and  bichloride  in  wet  dressings.  They 
always  irritate  the  skin,  and  may  cause  eczema  and  even  gangrene, 
particularly  of  the  fingers  and  toes.  Gangrene  results  partly  in  conse- 
quence of  the  direct  chemical  action  of  the  carbolic  acid  upon  the  tissue 
elements  of  the  cutis,  and  partly  from  the  marked  transudation  into 
the  subcutaneous  cellular  tissue,  causing  disturbances  of  the  circulation. 
The .  onset  of  gangrene  is  masked  by  the  anaesthetic  action  of  the 
carbolic.  Honsell  collected  from  literature  forty -three  cases  of  car- 
bolic gangrene,  particularly  of  the  fingers  and  toes  ;  in  thirty  of  the 
cases  the  strength  of  the  solution  was  only  one  to  five  per  cent.  I 
consider  carbolic  gangrene  rather  common,  most  of  the  cases  not  being 
reported.  The  sale  of  carbolic  solutions  to  the  laity  should  be  pro- 
hibited. What  has  been  said  of  carbolic  gangrene  is  true  of  bichloride 
gangrene,  which  is,  however,  rarer.  If  wet  applications  of  this  kind 
are  to  be  left  in  place  for  some  time,  possibly  one  or  two  days,  and  the 
effect  of  moist  heat  is  desired,  the  applications  should  be  covered  with 
rubber  tissue  over  which  cotton  is  laid,  and  the  whole  dressing  is  then 
fastened  in  position  by  a  bandage  (hydropathic  poultice  or  Priessnitz's 
poultice).  Wet  dressings  like  these,  particularly  if  made  with  lead- 
water,  or  one  per  cent,  acetate  of  aluminium,  have  a  powerful  stimu- 
lating action  upon  granulations,  and  the  skinning-over  process  is 
occasionally  very  much  hastened.  If  cold  is  aimed  at  in  the  wet  appli- 
cations, for  reduction  of  the  heat  in  any  given  portion  of  the  body,  the 
dressings  will  need  very  frequent  renewal. 


§49.]  OTHER  DRESSINGS   FOR   WOUNDS.  185 

Cold — Ice. — In  such  cases  it  is  best  to  use  ice  enclosed  in  rubber 
bags,  or  to  add  ice  or  snow  to  tbe  water  used  for  wetting  the  dressin2;s  ; 
or  else  make  a  cooling  mixture  consisting  of  one  part  ammonium  chlo- 
ride, three  parts  of  nitre,  six  parts  of  vinegar,  and  twelve  to  twenty- 
four  parts  of  water  (Schmucker). 

The  effect  of  ice  and  cold  applications  upon  the  wound  is  both 
analgesic  and  hsemostatic.  Lately,  Leiter,  of  Yienna,  has  invented  an 
apparatus  for  obtaining  in  the  most  satisfactory  manner  the  effect  of 
cold  and  heat  upon  inflamed  and  injured  portions  of  the  body.  It 
consists  of  a  pliable  metal  tube  through  which  water  at  any  required 
temperature  is  allowed  to  flow.  The  metal  tube  can  be  made  to  as- 
sume any  desired  form,  such  as  a  cap  for  the  head,  or  a  coil  for  encir- 
cling an  extremity,  or  a  flat  piece  for  the  back,  etc.  A  similar  appa- 
ratus has  been  made  of  rubber  tubing,  and  used  as  a  cold  coil  for  an 
extremity,  an  ice  cap  for  the  head,  or  an  ice  bag  for  the  neck.  By 
allowing  hot  water  to  run  through  the  apparatus,  heat  of  any  desired 
intensity  may  be  applied  to  a  part. 

Adhesive  Plaster. — Small  wounds  and  granulating  wounds  in  the 
later  stages  of  healing  may  be  covered  with  adhesive  plaster,  collodion,, 
ointments,  etc.  Adhesive  plaster  is  made  of  some  substance  like  linen, 
cotton,  silk,  leather,  etc.,  covered  upon  one  side  with  a  sticky  material 
such  as  litharge,  olive  oil,  resin,  or  turpentine,  etc. ;  lead  plaster  is  made 
with  certain  resinous  substances,  with  oil,  wax,  turpentine,  etc.  The 
ordinary  German  adhesive  plaster  is  usually  warmed  over  the  flame  of 
a  spirit  lamp  before  being  applied,  and  then  laid  in  strips  upon  the 
desired  portion  of  skin,  which  has  been  previously  dried.  To  prevent 
the  plaster  from  adhering  to  the  hairs,  the  latter  must  be  flrst  shaved 
off  with  a  razor.  On  sensitive  skin  ordinary  adhesive  plaster  easily 
gives  rise  to  eczema.  The  less  irritating  emplastrum  cerussee  is  to  be 
recommended  in  this  particular,  although  it  does  not  adhere  so  well. 

American  Adhesive  Plaster. — A  very  good  kind  of  sticking  plaster, 
though  somewhat  expensive,  is  the  American  adhesive  plaster  (Ellis's 
adhesive  plaster  cloth),  in  which  the  sticky  material  is  spread  on  mus- 
lin, linen,  or  silk. 

English  Adhesive  Plaster.  —The  English  plaster  adheres  very  well 
and  is  useful  for  small  wounds ;  it  consists  of  fine  sarcenet  having  on 
one  side  a  solution  of  isino-lass  and  on  the  other  tincture  of  benzoin 
{Emplastrum  adhesivum  anglicum).  The  sticky  side  should  be  mois- 
tened with  some  antiseptic  solution  and  not  with  saliva,  and  then  ap- 
plied to  the  skin. 

Paris  Plaster. — The  Paris  plaster  is  more  flexible  and  adheres  even 
better.     The  recently  invented  iodoform  plaster  consists  of  iodoform,. 


186  OTHER   METHODS   OF   TREATING   WOUNDS. 

glycerine,  and  mucilago  ginnmi  arabici,  which  is  made  into  a  solution 
and  spread  over  linen. 

There  are  many  other  kinds  of  adhesive  plaster  which  may  be 
found  in  the  Pharmacopceia.  Unna  has  introduced  a  very  excellent 
gauze  adhesive  plaster,  made  of  oxide  of  zinc  or  iodoform  spread  on 
gauze  with  some  sticky  substance,  and  it  is  often  preferable  to  the 
ordinary  adhesive  plaster.  Pick's  salicylic  soap  plaster  and  Beiers- 
dorf's  salicylic-acid  soap  plaster  are  both  useful. 

Collodion. — Of  the  other  adhesive  materials  I  should  mention  especially 
collodion,  which  is  a  solution  of  gun  cotton  in  ether  and  alcohol.  By  the 
evaporation  of  the  ether  and  alcoliol  the  collodion  dries  in  the  form  of  a  firm 
covering  which  adheres  excellently  to  the  skin.  It  is  not  suitable  for  apply- 
ing to  fresh  wounds  on  account  of  the  irritation  it  causes.  Iodoform  collo- 
dion (1  to  10)  is  frequently  used  as  a  protective  dressing,  and  it  is  far  better 
than  adhesive  plaster  in  that  it  does  not  come  off  by  contact  with  water.  A 
cutaneous  wound,  after  it  has  been  sutured,  is  frequently  painted  over  with 
iodoform  collodion  (Iviister,  Zweifel,  Hans  Schmidt),  and  heals  like  any 
wound  sutured  aseptically,  over  which  there  forms  a  dry  aseptic  scab.  Col- 
lodium  elasticum  (collodion  60,  castor  oil  2.5,  turpentine  7.5)  is  particularly 
suited  for  chapped  hands,  frost-bites,  etc. 

Substitutes  for  Collodion. — Pastes  of  different  kinds  may  be  used  as  sub- 
stitutes for  collodion.  Dermatol,  bismuth,  airol.  and  other  powders  can  be 
mixed  with  an  equal  amount  of  mucilago  quinina  arabicum  and  glycerine, 
to  form  a  good,  rapidly  drying  paste  which  is  used,  for  example,  for  sutured 
aseptic  wounds.  An  excellent  covering  for  a  wound  may  be  simply  and 
quickly  made  by  mixing  an  antiseptic  powder  with  bichloride  solution. 
Schleich  uses  blood  serum  in  the  form  of  a  paste  for  treating  wounds  and 
skin  diseases.  The  preparations  are  pasta  serosa,  pulvis  serosa  (with  iodo- 
form and  nuclein),  pasta  serosa  cum  hydrargyri,  etc.  Zinc  glue  (zinc  oxide 
and  gelatine,  aa  20.0,  with  glycerine  and  aq.  destill.  aa  80.0)  acts  in  the  same 
way  as  the  pastes. 

Photoxylin. — Wahl  has  recommended  photoxylin  in  place  of  collodion. 
It  is  a  substance  used  in  photography,  and  he  employs  it  in  a  five-per-cent. 
solution  in  equal  parts  of  alcohol  and  ether. 

Traumaticin.— Traumaticin,  or  a  solution  of  gutta-percha  in  chloroform, 
is  widely  employed  as  an  adhesive  dressing  in  place  of  collodion. 

Gummi  Laccse. — Gummi  laccse  (Mellez)  is  also  much  employed  as  a  sub- 
stitute for  collodion  and  English  adhesive  plaster.  A  solution  of  the  con- 
sistence of  jelly  made  by  adding  alcohol  is  warmed  and  spread  on  cloth,  thus 
forming  a  cheap  and  serviceable  adhesive  plaster  which  is  not  attacked  by 
water  or  fat,  etc.  Susteck  recommends  "cutin  "  as  a  covering  for  wounds. 
It  is  absorbable  and  can  be  sterilised.  It  is  made  from  the  intestine  of  the 
ox  and  is  very  delicate. 

Ointments. — Ointments  as  dressings  for  granulating  wounds  do  not 
enjoy  the  popularity  which  they  once  did,  and  I  rarely  use  them.  For 
granulating  wounds  I  like  wet  dressings  of  one-per-cent.  acetate  of 


§49.]  OTHER  DRESSINGS   FOR   WOUNDS.  187 

aluminium,  or  antiseptic  powders  such  as  bismuth,  zinc  oxide,  iodo- 
form, and  dermatol  with  or  without  an  ointment.  There  are  manj 
ointments,  of  which  the  principal  ones  are  boric-acid  ointment,  boro- 
glycerin  lanolin  (Graf),  vasehne,  salicylic  vaseline,  carbolised  vaseline, 
glycerine  ointment,  either  jDure  or  mixed  with  various  antiseptics,  zinc 
ointment,  lead  ointment,  naphthalene  ointment,  and  finally  casein  oint- 
ment, containing  casein,  alkalies,  glycerine,  vaseline,  water,  and  an 
antiseptic  adjuvant  (one  half  per  cent,  zinc  oxide  and  one  half  per 
cent,  carbolic  acid).  If  applied  with  water  the  latter  ointment  dries 
quickly  and  forms  a  very  smooth,  thin  covering.  An  excellent  base 
for  making  ointments  is  lanolin,  recommended  by  Liebreich,  in  which 
bacteria  cannot  grow.  Glycerine  fats,  on  the  other  hand,  become  easily 
rancid  under  the  influence  of  light,  and  then  become  a  good  medium 
for  the  growth  of  micro-organisms  (Frankel,  Gottstein). 

Kirsten  recommends  molhn  as  an  adjuvant  to  gray  mercurial  and 
iodine  ointments. 


CHAPTER   III. 

GENERAL    RULES    FOR    THE    APPLICATION    OF    BANDAGES    AND    RETENTION 

APPLIANCES. 


The  different  kinds  of  bandages. — The  application  of  the  ordinary  roller  bandage. — 
The  "  reverse." — The  removal  of  bandages. — The  rolling  of  bandages. — The  appli- 
cation of  bandages  to  particular  parts  of  the  body  (head,  neck,  trunk,  upper  and 
lower  extremities). — The  application  of  handkerchief  bandages  to  different  por- 
tions of  the  body. 

§  50.  Application  of  Bandages. — The  ordinary  bandages  are  made  of 
linen,  flannel,  muslin,  webbing,  or  gauze,  etc.  For  bandaging  wounds, 
as  we  have  said  before,  we  preferably  employ  sterilised  mull  or  starched 
gauze.  The  latter  are  first  soaked  in  a  1  to  1,000  solution  of  bichloride 
or  a  three-per-ceut.  carbolic  solution,  squeezed  dry,  and  then  applied 
in  a  damp  condition  to  the  selected  portion  of  the  body,  thus  making 
a  well-fitting  and  strong  permanent  dressing,  as  illustrated  in  Figs. 
14:3  and  144,  on  page  175. 

The  rubber  bandage  (made  from  ordinary  caoutchouc)  or  the  band- 
age of  elastic  webbing  is  used  when  it  is  desired  to  apply  a  dressing  to 

exert  pressure.  Elastic  bandages  are  adapted 
for  application  about  the  thorax,  the  abdo- 
men, etc.,  where  other  bandages  become  easily 
displaced  and  loosened.  There  are  both  sin- 
gle and  double  roller  bandages,  the  latter 
being  illustrated  in  Fig.  149.  Trii^le  and 
quadruple  rollers  were  formerly  much  in 
vogue,  and  can  be  easily  made  by  fastening  together  a  couple  of  ordi- 
nary bandages.  The  many-tailed  bandage,  as  it  is  called,  consists  of 
several  strips  of  bandage  overlapping  laterally  and  joined  in  the  centre 
by  a  single  cross  strip. 

Application  of  the  Roller  Bandage. — The  ordinary  roller  bandage  is 
applied  by  holding  the  end  of  the  bandage  upon  the  desired  spot  with 
the  index  finger  or  thumb  of  the  left  hand,  while  the  roller  is  directed 
upward  (Fig.  150).  The  first  turn  of  the  bandage  is  secured  by  a 
second,  making  two  thicknesses  of  the  bandage  at  one  place  ;  then 
188 


Fig.  1-19.— Double  roller 
bandasre. 


§50.] 


APPLICATION"  OF   BANDAGES. 


189 


the  bandage  is  unrolled  spirally  upwards  about  the  part,  making  each 
upper  turn  overlap  about  half  of  the  width  of  the  one  next  below.  I 
usually  apply  the  bandage  from  left  to  right.  If  it  is  desired  to  rap- 
idly secure  a  dressing  in  place,  each  spiral  turn  may  he 

separated  by  a  considerable  dis- 
tance from  the  next  lower  turn 
(Fig.  151),  and  subsequently  the 
bandage  may  be  comjDleted  in 
the  regular  way.  If  one  at- 
tempts to  apply  a  linen  or  gauze 
bandage,  for  example,  to  the 
upper  or  lower  extremity,  with 
circular  or  sj)iral  turns,  it  will 
soon  be  noticed  that  the  lower 
edge  of  each  turn  does  not  lit 
tightly  to  the  extremity,  and 
that  its  "  set,"  particularly  in 
the  case  of  the  forearm  and  leg,  is  uneven.  For  preventing  this  loose- 
ness of  the  lower  margin  of  each  turn,  and  to  make  the  whole  bandage 
fit  evenly  and  firmly,  it  is  customary  to  make  what  is  called  a  "  re- 
verse," which  is  best  done  as  follows  (Fig.  152)  :  1.  The  roller  is 
grasped  by  the  right  hand  in  such  a  way  that  one  looks  into  the  palm 
of  the  hand,  the  dorsal  surface  is  directed  downwards,  and  the  bandage 
drawn  tight  and  smooth  obliquely  upwards,  while  its  lower  edge  is  held 
firm  by  the  left  thumb  (Fig.  152,  a).  2.  The  traction  on  the  obliquely 
directed  portion  of  the  bandage  beyond  the  left  thumb  is  then  relaxed 
(Fig.  152,  h).     3.  The  upper  edge  of  the  bandage  is  then  folded  over 


IFiG.  150. — Application  of  the 
ordiDary  roller  bandage. 


Fi&.  151. — Spiral 
bandacre. 


b  c 

Fig.  152. — Application  of  the  reverse  bandage. 


downwards  (Fig.  152,  c).  The  points  of  reverse  should,  as  far  as  pos- 
sible, be  made  at  the  same  part  of  the  circumference  of  the  extremity, 
and  lie  one  above  the  other.  This  method  should  be  employed  not 
only  in  bandaging  an  extremity,  but  any  other  portion  of  the  body,  so 


100    APPLICATIOX  OP  BANDAGES  AND  RETENTION  APPLIANCES. 

as  to  make  the  turns  of  the  bandage  iit  into  the  ineqnahties  of  the 
particular  locality.  The  Ijandage  is  usually  completed  by  one  or  two 
circular  turns.  While  making  the  reverses  care  should  be  taken  that 
ridges  and  folds  are  not  allowed  to  form.  Considerable  practice  is 
necessary  in  order  to  be  able  to  put  one  on  quickly  and  accurately. 
The  end  of  the  bandage  should  be  fastened  in  place  with  a  safety-pin, 
or  it  may  be  slit  up  at  the  end  with  scissors,  or  simply  torn  length- 
wise in  the  middle,  if  it  is  a  muslin  or  gauze  bandage,  and  the  split 
ends  carried  around  the  extremity  in  opposite  directions  and  knotted 
together. 

A  bandage  is  taken  off  by  unwinding  the  turns  in  the  reverse  direc- 
tion to  which  they  were  put  on — i.  €.,  the  turn  last  applied  is  the  first 


Fig.  15-3. — Rolling  a  bandage.  Fig.  154. — Fascia  nodosa.  Fig.  155.— Mitra  Hippocratis. 

to  be  taken  off.  At  the  same  time  the  bandage  is  rolled  up,  and  during 
the  unwinding  is  quickly  passed  from  one  hand  into  the  other.  The 
removal  of  a  mull  or  gauze  bandage  is  generally  accomplished  by  sim- 
ply slitting  it  up  with  bandage  scissors. 

In  Fig.  153  is  illustrated  the  method  of  rolling  a  bandage.  Mull 
and  gauze  bandage  rolls  are  best  and  most  rapidly  made  by  means  of 
a  small  rolling  machine. 

Application  of  a  Bandage  to  the  Head. — The  method  of  applying 
bandages  to  the  head  is  illustrated  in  Figs.  154^157. 

Fig.  15-i  represents  the  fascia  nodosa  or  knotted  bandage.  The 
middle  of  a  strip  of  bandage  is  laid,  for  example,  on  the  left  temple, 
and  one  end  of  the  strip  is  carried  over  the  crown,  the  other  under  the 
chin  to  the  right  temple,  and  at  this  point  the  two  ends  are  crossed, 
the  one  which  came  from  under  the  chin  passing  around  the  forehead, 
the  other  around  the  occipital  region,  and  the  two  ends  are  then  knotted 
together.  The  principle  of  this  knotted  bandage  can  be  used  with 
some  variations  for  almost  any  desired  portion  of  the  body.  Its  chief 
use  is  for  exerting  pressure  on  some  particular  spot,  which  can  be 


§  50.]  APPLICATION   OF   BANDAGES.  191 

increased  by  inserting  beneath  the  bandage  a  pad  of  cotton  or  gauze, 
etc.  It  is  also  used  in  the  inguinal  region  (Fig.  183),  as  a  temporary 
substitute  for  a  hernia  truss. 

Mitra  Hippocratis. — The  mitra  Ilippocratis  (Fig.  155)  is  made  with  a 
double  roller,  or,  what  is  simpler,  with  an  ordinary  roller  bandage.  When 
the  double  roller  is  employed  its  centre  is  applied  in  the  middle  of  the 
forehead,  one  roller  being  carried  horizontally  around  the  head  towards 
the  right,  the  other  towards  the  left,  and  at  the  occiput  the  two  rollers 
are  crossed  in  the  manner  of  the  fascia  nodosa ;  then  an  assistant  car- 
ries one  roller  over  the  crown  to  the  forehead,  while  the  operator,  with 
the  second  roller,  takes  a  circular  turn  horizontally  around  the  head 
and  crosses  the  roller,  which  has  been  carried  over  the  crown,  upon  the 
forehead.  This  is  continued,  one  roller  being  carried  from  the  fore- 
head to  the  occiput  and  then  back  again  to  the  forehead,  first  on  the 
right  side  and  then  on  the  left  of  the  original  median  strip  carried 
sagittally  over  the  crown,  each  circular  turn  of  the  other  roller  securing 
the  strips  passing  over  the  crown.  The  entire  skull  is  thus  covered 
with  strips  of  bandage  running  forward  and  back  in  a  sagittal  direction. 
Finally,  the  ends  of  both  rollers  are  carried  circularly  around  the  head 
and  fastened  in  place  with  a  safety-pin.  The  mitra  Hi^Dpocratis  is  only 
occasionally  applied  with  a  double  roller,  but  it  is  well  to  understand 
the  principle  of  it  in  bandaging  wounds  of  the  head  (see  page  1Y5, 
Fig.  14:3).  A  mull  or  wet  gauze  bandage  may  be  applied  to  the  head 
partly  with  circular  turns  and  partly  with  turns  passing  back  and  forth 
in  a  sagittal  direction  over  the  top  of  the  head. 

Capistrum  Duplex. — The  capistrum  duplex  is  not  very  often  used 
now,  but  it  was  at  one  time  in  great  repute  for  treating  fractures  of  the 
lower  jaw,  as  was  also  the  capistrum  simplex.  The  funda  maxillae 
(Fig.  171:)  has  the  same  effect  as  the  capistrum  simplex 
and  duplex,  and  is,  furthermore,  much  better  and  sim- 
pler. Some  of  the  turns  made  in  the  capistrum  duplex 
are  used  for  applying  bandages  in  wounds  of  the  head 
and  neck,  and  hence  it  should  be  spoken  of  here.  The 
description  of  the  old-fashioned  capistrum  simplex  will 
be  omitted.  The  capistrum  duplex  is  begun  with  the 
end  of  the  roller  on  the  vertex,  then  it  passes  down  in 
front  of  the  left  ear,  under  the  chin,  and  up  in  front  Capibtium  duplex. 
of  the  right  ear  to  the,  vertex  again ;  then  from  this 
point  it  passes  around  the  occiput  to  the  right  side  of  the  neck,  under 
the  chin,  and  up  in  front  of  the  left  ear,  covering  the  first  turn  in  great 
part,  back  to  the  vertex  again  ;  then  around  the  occiput  to  the  left  side 
of  the  neck,  beneath  the  chin,  and  up  in  front  of  the  right  ear  to  the 


192    APPLICATION  OF  BANDAGES  AND  RETENTION  APPLIANCES. 

vertex.  In  this  way  three  turns  of  the  bandage  are  made  in  front  of 
each  ear,  and  then  it  is  carried  from  the  neck  in  front  of  tlie  cliin  and 
the  lower  ])art  of  the  under  Hp,  and  is  tinally  terminated  by  a  circular 
turn  around  tlie  forehead  and  occiput.  The  circular 
turn  around  the  front  of  the  chin  can  be  made  between 
the  second  and  third  turns  taken  in  front  of  the  ear. 
In  applying  it  over  an  antiseptic  dressing  tlie  neck 
should  also  be  included  in  the  bandage. 

Monoculus  and  Binoculus. — Fig.  15T  represents  the 
metliod  of  applying  the  monoculus,  which  begins  with 
a   circular   turn   about   the   liead,  starting   from   the 
temporal  region.     The  rest  can  be  understood  from 
Fig.  157.     The  so-called  binoculus,  or  bandage  over 
iDoth  eyes,  is  pei'formed  bj  first  covering  one  eye  with  a  circular  turn 
of  the  bandage  and  then  carrying  the  bandage  with  obliquely  descend- 
ing turns  over  the  other  eye. 

Application  of  a  Bandage  to  Neck  and  Thorax. — The  application  of 
bandages  to  the  neck  is  accomj)lished  by  making  circular  turns,  to 
which,  in  the  case  of  large  wounds,  are  added  cross  turns  under  the 
axilla  and  over  the  shoulder  (see  page  175,  Fig.  141:).  Bandages  are 
applied  to  the  thorax  by  circular  tui-ns,  with  or  without  reverses.  To 
keep  the  bandage  from  becoming  displaced,  every  other  turn  can  be 
carried  from  the  back  over  the  shoulder  and  secured  with  safety-pins 
at  the  points  of  meeting  with  the  horizontal  turns  ;  or  the  circular 
turns  may  be  made  to  ascend  from  below  upwards  on  the  thorax,  and 
finished  by  oblique  turns  about  the  shoulder  and  axilla  like  a  spica 
humeri  (Figs.  163  and  164).  For  bandaging  a  wound,  after  applying  a 
thick  cushion  of  dressings,  we  employ  starch  bandages,  which,  after 
dicing,  fit  closely  and  do  not  become  easily  displaced.  Elastic  band- 
-ages  are  also  to  be  recommended  for  the  trunk,  as  they  retain  their 
position  very  well. 

Bandages  for  the  Breast.  Suspensorium  3fammce  Simplex  (Fig.  158). 
— The  bandage  for  the  right  breast  is  begun  by  a  circular  turn  about 
the  lowermost  portion  of  the  thorax.  The  bandage  is  then  carried 
obliquely  so  as  to  envelop  the  lower  part  of  the  gland,  over  the  oppo- 
site shoulder,  then  across  the  axilla,  over  the  shoulder  and  across  the 
back,  again  to  the  right  breast  at  its  upper  part,  and  then  once  more 
over  the  shoulder,  etc.  The  upper  and  lower  portion  of  the  gland  is 
crossed  alternately,  and  then  its  middle  part,  and  finally  the  bandaging 
is  completed  by  a  circular  turn  around  the  lowermost  portion  of  the 
thorax  covering  the  preliminary  turns  (Fig.  158).  The  suspensorium 
iDammge  duplex  and  a  light  supporting  bandage  for  both  breasts  can 


50.] 


APPLICATION  OF   BANDAGES. 


193 


be  applied  verj  simply  by  using  the  method  illustrated  in  Fig.  158  on 
both  sides. 

Antiseptic  Retention  Dressing  after  Amputation  of  the  Breast  and  clean- 
ing out  the  Axilla. — After  amputation  of  the  breast,  accompanied  by  clean- 
ing the  carcinomatous  lymphatic  glands  out  of  the  axilla,  I  first  put  on  a 
dressing  of  several  layers  of  sterilised 
^auze  placed  in  direct  contact  with  the 
wound,  then  over  this  I  apply  absorb- 


FiG.  158. — Suspensorium  mammae 
duplex  and  small  outer  bandage 
for  the  mamma. 


Fig.  159. — Aseptic  dressing  for  use  after  an 
amputatio  mammse  with  cleaning  out  of  the 
left  axilla. 


■ent  cotton,  covering  in  the  shoulders  and  entire  thorax.  These  materials  are 
then  bound  on  by  a  sterilised  mull  bandage  encompassing  the  thorax,  neck, 
and  shoulders,  the  edges  of  the  dressings,  particularly  in  the  axilla,  neck,  and 
at  the  lower  border  of  the  breast,  being  very  carefully  filled  in  with  absorbent 
•cotton ;  then  the  arm  on  the  side 
which  has  been  operated  upon  is 
placed  in  contact  with  the  thorax 
and  also  covered  with  sterilised 
absorbent  cotton.  After  this  the 
arm  is  immobilised  by  a  steril- 
ised mull  and  finally  a  gauze 
l)andage  encircling  the  thorax, 
neck,  and  shoulder  (Fig.  159). 

Application  of  Bandages  to 
the   Upper    Extremity.  —  The 

methods  of  applying  bandages 
to  the  fingers  are  illustrated 
in  Fig.  160,  «,  h,  c.  They  are 
begun    with   a   circular    turn 

around  the  wrist,  and  then  carried  across  the  dorsum  of  the  hand  to 
any  particular  finger,  and,  after  encircling  it,  brought  back  again  to 
the  back  of  the  wrist  (Fig.  160,  a).     A  finger  can  be  bandaged,  as 
14 


Fig.  160. — Application  of  bandages  to  the  fingers. 


194    APPLICATION  OP  BANDAGES  AND  RETENTION  APPLIANCES. 


illustrated  for  the  little  linger  in  Fig.  100,  c,  by  making  oblicjue  s])iral 
turns  down  to  its  tip,  and  then  covering  in  the  linger  hy  oblique  or 

circular  turns  from   tip  to  base.     The  linger  bandage 

can  also  be  carried  in  the  reverse 

direction,  beginning   on  the  lin 

ger  and  terminating  at  the  wrist. 

Moreover,  the  thumb  may  be  band- 
aged in  the  way  pictured  in  Fig. 

160,  h  •  beginning  with  a  circular 

turn  around  the  wrist,  the  bandage 

is  carried  to  the  tip  of  the  thumb, 

and  around  this,  over  the  back  of 

the  hand,  and  so  on,  with  oblique 

turns  till  the  base  of  the  thumb  is 

reached.    If  it  is  desired  to  band- 
age the  tip  of  the  finger,  the  roller 
is  carried  along  the  back  or  palmar  surface  of  the  finger  over  its  tip 
and  back  on  the  other  side  opposite  the  starting-point,  where  it  is 
retained  while  a  circular  turn  is  made  around  the  base 
of  the  finger,  over  the  ends  of  the  loop,  securing  it  in 
its  position.     A  bandage  is  applied  to  the  whole  hand 
according  to  the  rules  for  the  spica  manus  (Fig.  161). 
The  bandage  is  started  at  the  wrist  by  a  circular  turn, 
and  then  oblique  or  figure-of-eight  turns  are  taken  by 
the  roller,  gradually  proceeding  downwards  till  the 


Fig.   161. — Spica 
manus. 


Fio.  162.- 


•Bandage  for  the- 
hand. 


-1 


Fig.  163. — Spica  humeri 
ascendens. 


Fig.  164. — Spica  humeri 
descendens. 


Fig.  165.— Bandage 
for  the  entire  up- 
per extremity. 


finger  ends  are  reached.     It  is  concluded  with  a  circular  turn  about 
the  wrist. 

Another  way  of  bandaging  the  hand  is  represented  in  Fig.  162,  a. 


§50.]  APPLICATION  OF  BANDAGES.  195 

and  h.  It  is  begun  with  a  circular  turn  around  the  wrist  (Fig.  162,  o) 
or  around  the  ends  of  the  fingers,  and  j)roceeds  up  or  down  with  figure- 
of-eight  or  oblique  turns,  half  of  the  width  of  each  upper  turn  overlap- 
ping a  corresponding  amount  of  the  next  lower  turn,  and  finally  termi- 
nating with  a  circular  turn  around  the  finger  tips  or  the  wrist.  If  it  is 
desired  to  include  the  finger  tips,  as,  for  instance,  in  an  antiseptic  pro- 
tective dressing,  the  end  of  the  bandage  is  secured  while  the  roller  is 
carried  over  and  around  the  ends  of  the  fingers  and  back  on  the  oppo- 
site side  in  the  form  of  a  loop,  and  the  extremities  of  the  loop  are  then 
fastened  in  place  by  a  circular  turn. 

Application  of  a  Bandage  to  the  Shoulder. — The  shoulder  is  bandaged 
by  using  the  spica  humeri  ascendens  (Fig.  163)  or  descendens  (Fig. 
164).  The  spica  humeri  ascendens  (Fig.  163)  begins  with  a  circular 
turn  around  the  uj)per  end  of  the  arm,  the  bandage  being  then  carried 
over  the  lower  end  of  the  shoulder  from  within  outwards,  then  over 
the  back  to  the  opposite  axilla  and  back  again  across  the  breast  over  the 
shoulder  through  the  axilla,  and  finally  terminated  by  a  circular  turn 
around  the  thorax.  The  spica  humeri  descendens  (Fig.  164)  is  applied 
in  the  reverse  direction — i.  e.,  it  is  begun  with  a  couple  of  circular 
turns  about  the  thorax,  and  finished  with  descending  oblique  or  cross 
turns  over  the  shoulder,  terminating  on  the  arm  lower  down,  or  with 
a  circular  turn  about  the  thorax  again.  Fig.  165  represents  the  method 
of  applying  a  bandage  to  envelop  the  whole  arm.  The  turns  of  the 
spica  humeri  around  the  thorax  are  omitted  in  the  illustration  in  order 
to  economise  space,  but  the  rest  of  the  figure  illustrates  the  bandage 
for  the  entire  upper  extremity. 

Application  of  Bandages  to  the  Lower  Extremity. — The  bandage  for 
the  lower  extremity  is  begun  by  enclosing  the  foot  (Fig.  166,  a  and  h) 
by  a  circular  turn  made  back  of 
the  toes,  as  illustrated  in  Fig. 
166,  a ;  then  two  or  three  slight- 
ly oblique  turns  are  taken,  with 
or  without  the  reverse  (Fig.  152), 
and  at  about  the  fourth  turn  of 
the  bandage  the  latter  is  carried 
obliquely  over  the  anterior  as- 
pect of  the  ankle-joint  toward  a   ^^^  b 

the  internal  malleolus,  and  from         Fig.  166.— Application  of  bandages  to  the  foot. 

here  over  the  heel  and  around 

the  outer  malleolus  again  to  the  inner  side  of  the  foot ;  thence  across 
the  sole,  making  two  or  three  stirrup  turns,  and  then  ascending  the  leg 
with  circular  turns,  followed  by  oblique  turns  and  the  reverse  (Fig. 


196    APPLICATION  OF  BANDAGES  AND  RETENTION  APPLIANCES. 

152).  If  the  lieel  is  to  be  iucluded  (Fig.  16G,  6),  the  haudage  is  begun 
as  in  Fig.  166,  «  ;  but  after  taking  two  or  three  turns,  it  is  carried  across 
the  dorsum  of  the  foot  to  the  heel,  around  the  latter,  over  the  dorsum 
to  the  inner  side  of  the  foot,  thence  across  the  sole  to  the  outer  side  of 
the  foot,  again  over  the  dorsum  to  the  heel,  each  preceding  turn  being 
covered  by  half  the  wadth  of  the  following  turn,  and  so  on  till  above 
the  ankle,  when  two  circular  turns  are  made,  and  then  these  are  suc- 
ceeded by  oblique  turns  with  reverses  ascending  the  leg. 

For  applying  a  bandage  to  the  region  of  the  knee-joint  the  testudo 
inversa  (Fig.  167,  a  and  V)  or  reversa  (Fig.  168,  a  and  V)  is  used.  In 
the  testudo  inversa  (Fig.  167),  after  several  circular  turns  are  made 
around  the  \q^^  an  oblique  turn  is  carried  across  the  popliteal  space 
toward  the  thigh,  passing  around  the  latter  back  across  the  popliteal 
space  to  the  leg  and  so  on  gradually  covering  in  first  the  lower,  then 


^^ 


Fig.  167. — Testudo  inversa  genus. 


Fig.  168. — Testudo  reversa  genus. 


the  upper  part  of  the  anterior  aspect  of  the  knee,  the  last  turn  crossing 
the  centre  of  the  anterior  aspect  of  the  knee  transversely  (Fig.  167,  5). 
The  testudo  reversa  is  begun  with  a  circular  turn  around  the  middle 
of  tlie  knee,  and  the  remaining  turns  are  made  obliquely,  first  above 
and  then  below  the  original  circular  turn. 

The  testudo  bandage  is  also  employed  for  the  elbow. 

AVhen  it  is  desired  to  include  the  entire  lower  extremity  in  a  band- 
age, the  region  of  the  knee  may  be  covered  simply  by  circular  turns 
(Fig.  171).  The  hip,  in  the  same  way  as  the  shoulder,  may  be  band- 
aged by  a  spica  coxae  ascendens  (Fig.  169)  or  descendens  (Fig.  170). 
The  spica  coxse  ascendens  is  begun  with  a  circular  turn  around  the 
upper  part  of  the  thigh,  and  then,  in  the  case  of  the  left  hip,  the  band- 
age is  carried  across  the  gluteal  and  sacral  region  towards  the  opposite 
anterior  superior  spine  of  the  ilium,  thence  over  the  lower  part  of  the 
abdomen  and  inguinal  region  back  to  the  thigh.     For  the  right  thigh. 


51.] 


APPLICATION  OF   HANDKERCHIEF   BANDAGES. 


197 


the  bandage  is  carried  over  the  groin  and  abdomen  to  the  anterior 
superior  spine,  thence  across  the  sacral  and  ghiteal  regions  back  to  the 
thigh.     Each  succeeding  turn  ascends  a  little  higher 
on  the  thigh,  and  the  bandage  is  finally  completed  by 
a  circular  turn  around  the  abdomen.     The  spica  coxae 


Fig.  169. — Spica  coxae 
ascendens. 


Fig.  170. — Spica  coxae 
descendens. 


Fig.  171.— Bandage 
for  the  entire  lower 
extremity. 


descendens  (Fig.  170)  is  begun  where  the  ascendens  terminates,  by  cir- 
cular turns  around  the  abdomen,  and  is  made  to  descend  by  oblique 
turns  in  a  manner  the  reverse  of  the  spica  ascendens,  and  finally  to  come 
down  the  thigh  by  circular  and  oblique  turns  made  with  reverses.  The 
method  of  bandaging  the  entire  lower  extremity  will  be  understood 
from  the  previous  remarks  (Fig.  171). 


Fig.  172. — Double  piece  of  cloth  ; 
bandage  to  support  the  jaw. 


Fig.  17S.— Handkerchief  or  impromptu 
cloth  bandage  for  the  jaw. 


Fig.  174. 
Funda  raaxillse. 


§  51.  Application  of  Handkerchief  Bandages.— Properly  shaped  pieces 

of  cloth  as  substitutes  for  bandages  are  not  suitable  for  dressing  wounds 
antiseptically,  but  under  other  circumstances — viz.,  for  applying  a  light 


198    APPLICATION  OF  BANDAGES  AND  RETENTION  APPLIANCES. 


protective  dressing,  or  for  the  after-treatment  of  a  wound,  or  in  an 
emergeuej — tbey  do  very  well,  and  possess  the  advantage  that  the  ma- 
terial for  making  them  can  always  be  obtained  in  every  household. 
These  bandage  substitutes  are  made  of  triangular  or  quadrilateral-shaped 
pieces  of  cloth.  One  of  the  most  useful  of  these  bandage  substitutes  is 
the  sling  bandage.  The  base  or  longest  of  the  three  sides  of  a  trian- 
gular piece  of  cloth  is  cut  in  the  manner  indicated  by  the  dotted  lines  in 
Fig.  172,  thus  making  a  five-tailed  piece  of  cloth,  which  is  excellent  as 
a  bandage  for  the  inferior  maxilla  (Fig.  174).  Another  very  good 
bandage  substitute  may  be  made  by  splitting  the  smaller  sides  of  a  long 
rectangular  piece  of  cloth  and  applying  it  as  a  bandage  for  the  head  in 
the  manner  indicated  in  Fig.  173,  a  and  h. 

These  pieces  of  cloth  used  as  bandage  substitutes  may  either  be 
folded  up  in  the  shape  of  a  cravat  and  made  to  encircle  any  part  of 
the  body,  or  they  may  be  used  as  simple  unfolded  pieces  of  cloth. 
The  folded  strips  are  applied  like  any  ordinary  roller  bandage.  For 
the  sake  of  brevity  I  shall  confine  myself  to  the  following  short  de- 
scription of  the  different  methods  of  using  these  substitutes  for  roller 
bandages. 

As  regards  the  head,  a  triangular  piece  of  cloth  folded  into  the 
shape  of  a  cravat  is  an  excellent  substitute  for  the  monoculus  in  band- 
aging the  eye,  and  for  making  a  hori^iontal  bandage  on  the  forehead 
like  the  fascia  nodosa  (Fig.  154).  A  very  useful  bandage  as  a  tem- 
porary dressing  for  a  fracture  of  the 
upper  or  lower  jaw  is  the  funda  raax- 
illse  (Fig.  174),  which  is  made  from 
the  five-tailed  sling  bandage  repre- 
sented in  Fig.  172.  The  three-cor- 
nered piece  is  folded  up  like  a  cravat, 
the  middle  of  which  is  placed  under 
the  chin  of  the  patient,  and  the  two 
ends  are  knotted  together  upon  the 
top  of  the  head.  The  point  of  meet- 
ing of  the  other  two  tails  is  held  in 
front  of  the  chin,  and  the  ends  of  these  tails  carried  around  the  back 
of  the  neck,  where  they  are  crossed  and  brought  forward  and  knotted 
together  on  the  forehead.  Mention  should  also  be  made  of  the  capi- 
tium  parvum,  magnum,  and  quadrangulare. 

The  Small  Head-dress  {Cajntium  parvum.  Fig.  175). — An  ordi- 
nary triangular  piece  of  cloth  is  laid  over  the  head,  with  the  centre  of 
its  longest  side  at  the  root  of  the  nose,  and  its  apex  or  angle  opposite 
the  longest  side  hanging  down  the  neck.     The  lateral  tails  of  the  tri- 


FiG.  175. — Capitium 
parvuiu. 


Fig.  176.— Large 
handkerchief  band- 
acre  for  the  head. 


§51.] 


APPLICATION  OF   HANDKERCHIEF  BANDAGES. 


199 


angle  are  carried  around  the  neck  back  to  the  forehead,  where  they  are 
tied  together.     The  tail  hanging  down  the  neck  is  turned  back  over 
the  top  of  the  head 
and  secured   with  a 
safetj-pin. 

The  Large  Head- 
dress ( Capitium 
magnum^  Fig,  176). 
—  The  triangular 
sling  bandage  is  cut 
in  the  manner  rep- 
resented in  Fig.  172 
and  laid  on  the  scalp, 
with  the  centre  of 
its  longest  side  at  the 

root  of  the  nose.  The  two  anterior  tails  hanging  down  on  each  side 
of  the  face  are  passed  around  the  neck,  as  in  the  capitium  parvum, 
and  brought  forward  and  knotted  together  on  the  forehead.  The 
other  two  tails  are  tied  under  the  chin,  and  the  apex  of  the  triangular 
piece  of  cloth  is  finally  brought  forward,  as  in  the  capitium  parvum, 
from  beneath  the  tails,  crossed  behind  the  neck,  and  secured  in  front 
by  a  safety-pin. 

The  Four-tailed  Head-dress  {Capitium  quadrangulare,  Fig.  177,  a). 
— A  quadrilateral  piece  of  cloth  is  so  folded  over  the  top  of  the  head 
that  its  under  border  overlaps  the 
upper  by  about  a  handbreadth  (Fig. 


Fig.  177. — Capitium  quadrangulare. 


Fig.  178. — Handkerchief  bandage 
for  the  breast. 


Fig.  179. — Handkerchief  bandage 
for  the  breast. 


177,  a).  The  two  upper — or,  rather,  posterior — angles  are  knotted  to- 
gether under  the  chin,  while  the  other  two  corners  are  drawn  some- 
what forward  and  upwards.  Then  the  projecting  lower  edge  of  the 
under  portion  of  the  cloth  is  turned  up  and  back,  and  the  two  anterior 


200    APPLICATION  OF  BANDAGES  AND  RETENTION  APPLIANCES. 

corners  are  carried  around  behind  the  neck  and  tied,  thus  forming  the 
bandage  represented  in  Fig.  177,  h. 

An  ordinary  three-cornered  piece  of  cloth  can  be  apphed  to  the 
thorax  in  the  manner  illustrated  in  Fig.  17S.  The  longest  side  of  the 
triangle  is  placed  around  the  lower  portion  of  the  thorax,  while  the 
apex  or  opposite  angle  of  the  triangle  is  carried  over  either  the  right 
or  left  shoulder  and  tied  to  the  other  two  tails  or  angles  of  the  triangle 
behind. 

In  suitable  cases  a  bandage  may  be  apjDlied  as  in  Fig.  179 — i.  e.,  a 
folded  piece  of  cloth  is  placed  around  the  thorax  and  prevented  from 
becoming  displaced  by  a  couple  of  retention  straps  carried  over  the 
shoulders  and  having  their  junctions  with  the  breast-piece  secured  by 
safety-pins.  The  female  breast  can  be  supported  by  an  ordinary  tri- 
angular piece  of  cloth,  or  one  made  double,  as  shown  in  Fig.  172.    The 


Fig.  180. — Handkerchief  bandage 
for  supporting  the  mamma. 


Fig.  181. — Arm-sling. 


sling  is  applied  with  the  centre  of  the  base  of  the  triangle  beneath  the 
breast  which  it  is  desired  to  support.  Then  the  lower  tails  or  corners 
at  each  side  of  this  point  are  carried  around  the  thorax,  while  the  other 
three  tails  are  conducted  across  the  axilla  and  over  both  shoulders  to 
the  back,  where  they  are  tied  together. 

The  triangular  piece  of  cloth  is  very  frequently  used  for  making 
the  so-called  mitella,  or  sling  (Fig.  181).  The  following  is  the  method 
of  applpng  the  mitella :  The  three-cornered  piece  of  cloth  is  grasped 
at  each  extremity  of  one  of  the  shorter  sides  and  placed  between  the 
thorax  and  the  arm  bent  at  right  angles,  ^vitll  one  angle  of  the  triangu- 
lar cloth  projecting  around  back  of  the  elbow.  The  upper  end  of  the 
longest  side  is  then  carried  over  the  opposite  shoulder  and  tied  to  the 
other  end  of  the  longest  side  behind  the  neck.  The  third  corner  or 
angle  of  the  triangular  cloth  is  carried  around  the  back  of  the  elbow 
to  the  front  and  secured  in  this  place  by  a  safety-pin  (Fig.  181,  a).  In- 
stead of  bringing  this  third  angle  around  in  front  of  the  elbow,  it  can 


g51-] 


APPLICATION   OF   HANDKERCHIEF   BANDAGES. 


201 


be  turned  in,  and  then  the  two  edges  of  the  sling  can  be  pinned  behind 
the  arm,  as  represented  in  Fig.  181,  h.     Moreover,  it  is  a  very  good 


Fig.  182— Handkeichief 

bandage  for  the  shoulder  or 

axilla. 


Fig.  183. — Knotted  bandage 
about  the  ino-uinal  reo-ion. 


Fig.  184.— Handkerchief 

bandage  about  the  inguinal 

region. 


plan  not  to  tie  the  ends  of  the  sling  around  the  neck,  as  the  knot  causes 
discomfort,  but  to  bring  the  extremities  to  the  front  again,  and  either 
sew  or  j)in  them  in  that  position. 

A  four-tailed  or  four-cornered  piece  of  cloth  can  be  used  for  a  sling, 
like  the  mitella,  but  the  manner  of  its  application  is  more  complicated, 
without  being  any  better. 

Strips  of  bandage  can  be  used  instead  of  the  mitella.  They  are 
fastened  to  the  coat  or  tied  at  the  back  of  the  neck.  Slings  can  also 
be  made  of  stout  black  ribbon,  which  encircle  the  arm  and  pass  around 
the  neck.  The  arm  may  also  be  supported  by  insert- 
ing the  hand  in  the  waistcoat  or  partially  buttoned  coat. 


Fig.  185.— Hand- 
kerchief band- 
age for  the  hand. 


Fig.  186.— Handkerchief 
bandage  for  the  foot. 


Fig.  187.— Hand- 
kerchief bandage 
for  the  liand. 


Fig.  188.— Handker- 
chief bandage  for 
the  foot. 


In  Figs.  182  to  186  are  represented  the  methods  for  applying 
pieces  of  folded  cloth  around  the  axilla  or  the  shoulder,  about  the  in- 
guinal region,  the  hand,  and  foot,  and  they  need  no  further  explaua- 


202    APPLICATION  OF  BANDAGES  AND  RETENTION  APPLIANCES. 

tion.  In  Fig.  183  the  principle  uf  the  fascia  nodosa  (Fig.  154)  is  used 
-^i.  e.,  the  ends  of  the  bandage  are  twisted  about  each  other  for  exert- 
ing pressure  upon  some  particular  spot.  By  means  of  a  pad  of  cotton, 
lead,  rubber,  or  other  material,  the  pressure  can  be  increased. 

In  Figs.  185  and  186  are  represented  the  methods  of  applying  a 
bandage  substitute  to  the  hand  and  foot.  The  hand  is  wrapped  in  a 
three-cornered  piece  of  cloth  in  the  following  manner  (Fig.  187):  The 
centre  of  the  base  of  the  triangle  is  placed  at  the  wrist,  while  the  angle 
opposite  the  base  projects  a  little  beyond  the  tijjs  of  the  lingers.  This 
projecting  angle  is  then  turned  back  over  the  lingers  and  dorsum  of 
the  hand  to  the  wrist,  the  lateral  angles  are  given  a  turn  around  the 
wrist  and  made  to  cross  each  other  on  the  dorsum  of  the  hand,  then 
brought  back  to  the  wrist  and  tied.  The  same  method  is  carried  out  on 
the  foot,  but  instead  of  knotting  the  ends  around  the  leg,  they  can  be 
carried  back  from  the  \eg  and  crossed  over  the  dorsum  of  the  foot,  and 
finally  tied  after  making  a  circular  turn  around  the  foot  (Fig.  188). 


CHAPTEK  lY. 

THE    SICK-BED    OF    THE    PATIENT. IMMOBILISATION    APPLIANCES    AND 

DRESSINGS. 

The  sick-bed  of  the  patient. — The  bed. — Adjustable  beds. — Bed  fittings :  Air-cushions ; 
■water-cushions. — Supports. — Wire  cradles. — Appliances  for  lifting  patients. — Ap- 
pliances for  the  sick-bed:  Cushions;  straw  splints. — Single  and  double  inclined 
plane. — Petit's  leg  splint. — Suspension. — Wire  gutters  and  baskets. — Splints. — 
Materials  for  making  splints  (wood  splints,  paste  splints,  metal  splints,  glass 
splints,  plaster  splints,  extension  splints,  articulated  splints). — Complicated  appli- 
ances for  the  sick-bed. 

§  52.  The  Sick-bed  of  the  Patient. — The  greatest  care  must  be  exer- 
cised as  regards  the  sick-bed  of  the  surgical  patient.  The  bed  should 
be  so  arranged  that  the  injured  portion  is  easily  accessible  to  the 
physician.  In  general,  it  is  best  to  place  the  head  of  the  bed  towards 
the  window,  to  prevent  the  patient  from  being  blinded  by  the  light. 
It  should  be  as  elastic  as  possible,  and  a  spring  or  horse-hair  mattress 
is  far  preferable  to  a  feather  bed.  If  the  patient  must  be  confined  to 
bed  for  a  long  time,  it  is  a  very  good  plan  to  have  a  bedstead  with 
contrivances  for  changing  its  shape,  so  that  he  can  readily  be  brought 
from  the  horizontal  into  a  sitting  position.  A  bedstead  which  the 
patient  can  adjust  to  suit  himself  with  very  little  effort  is  particularly 
good.  For  raising  and  moving  a  bed  without  disturbing  the  patient 
special  apparatus  have  been  devised  by  Allzeit  and  others.  A  water- 
tight rubber  protective  should  be  placed  over  the  mattress  to  prevent 
it  from  getting  wet.  "  Christia,"  a  comparatively  cheap,  durable,  and 
sterilisable  preparation,  has  been  recommended  by  Evens  and  Pistor, 
of  Cassel,  as  a  substitute  for  the  ordinary  water-tight  substances  hith- 
erto used  (rubber,  oiled  silk,  gutta-percha,  muslin,  etc.).  The  greatest 
care  must  be  used  to  keep  the  bed-linen  perfectly  clean,  so  that  the 
dressings  shall  remain  antiseptic.  If  the  patient  must  lie  for  a  long 
time  upon  his  back,  the  sacral  region  particularly  should  be  protected 
from  all  injurious  pressure  by  means  of  elastic  cushions.  For  this  pur- 
pose we  use  ring-shaped  air-cushions,  or,  what  is  still  better,  large 

water-cushions  filled  with  warm  water. 

203 


204 


THE   SICK-BED   OF  THE   PATIENT. 


Fig.  189. — Wire  cradle  for  the  limbs. 


A  swinging  crane  may  be  placed  over  the  head  of  the  bed,  or  a 
sling  attached  to  the  foot  of  the  bed,  so  as  to  enable  the  patient  to  raise 
himself.     By  means  of  hoops  joined  together,  or  cradles  (Fig.  189), 

the  bed-clothes  can  be  elevated  from 
the  diseased  portion  of  the  body  upon 
which  their  pressure  may  be  uncom- 
fortable, or  sometimes  even  painful. 

For  lifting  the  patient  or  some  j3or- 
tion  of  his  body  with  as  little  disturb- 
ance as  possible,  we  make  use,  when 
necessary,  of  special  appliances  called 
lifts.  In  the  majority  of  instances 
they  are  not  needed  for  changing  the  dressings  or  bed-clothes,  or  for 
enabling  the  patient  to  empty  his  bowels,  and  a  nurse  can  render  all 
the  assistance  required  ;  but  under  many  conditions — for  example,  when 
the  dressings  on  a  compound  fracture  have  to  be  renewed,  and  the  part 
must  be  held  lifted  up  from  the  bedding  for  some  time  while  it  is 
being  done — we  employ  windlasses,  pulleys,  belts,  fenestrated  scaffolds, 
etc.  The  portable  fenestrated  bed -lift,  which  permits  of  extension  and 
of  defecation  in  the  recumbent  position,  invented  by  Hamilton  and 
Yolkmann  (Fig.  190),  and  Hase's  apparatus  (Illustr.  Monatschrift  d. 
arzt.  Polytech.,  Heft  6,  1883),  are  very  useful  contrivances.  Yolk- 
mann's  bed-lift  is  placed  on  the  bed  over  the  mattress  and  can  be  raised 
by  two  attendants, 
while  the  supports  at 
each  extremity  can 
be  automatically  ad- 
justed so  that  the 
apparatus  can  be  re- 
tained at  any  desired 
elevation.  For  ele- 
vating any  single  por- 
tion of  the  body,  such 
as  an  extremity,  the 
ordinary  suspension 
apparatus  will  be 
found  sufficient  (Fig. 

194).  For  enabling  the  patient  to  raise  the  upper  portion  of  his  body, 
cranes  can  be  devised  ^vith  two  ropes  and  rings  for  him  to  grasp,  or 
straps  can  be  attached  to  the  ceiling  or  to  the  foot  of  the  bed.  The 
pelvis  of  the  patient  may  be  lifted  by  a  trestle  on  which  is  stretched  a 
broad  leather  belt  provided  with  a  fenestrum  for  permitting  evacua- 


FiG.  190.- 


-Elevated  frame  for  fractures  of  the  vertebrae  and 
pelvis  (Hamilton,  Volkmann). 


§53.] 


SICK-BED  APPLIAXCES— SPLIXTS,  CUSHIONS,  ETC. 


205 


Fig.  l&l. — Straw  splint  for  tem- 
porary use. 


tion  of  the  bowels.  But  if  it  is  impracticable  to  disturb  the  position 
of  the  patient  at  all,  an  opening  can  be  provided  in  the  mattress  and 
bottom  of  the  bed  for  enabling  liim  to  empty  his  bowels,  or  an  arrange- 
ment can  be  made  by  whieli  the  mattress  may  be  drawn  from  under 
him.  The  adjustable  bed  of  Hamilton  and  Yolkmann  is  exceedingly 
well  adapted  for  this  purpose. 

§  53.  Sick-bed  Appliances — Splints,  Cushions,  etc. — There  are  numer- 
ous apparatus  and  contrivances  for  obtaining  the  necessary  and  secure 
position  of  a  patient  who  is  confined  to  bed,  or  of  the  particular  part 
of  the  patient  which  has  been  operated  upon. 

1.  Cushions. — The  most  useful  cushions  for  retaining  a  diseased  part 
in  any  required  secure  position  are  made  of  chaff,  chopped  straw,  saw- 
dust, or  sand.  The  cushions  should  be  only  partially  filled,  so  that  the 
contents  may  be  shifted  and  the  cushion  given  any  desired  shape  for 
fitting  the  injured  extremity  and  holding 
it  securely.  Sand-bags  or  cushions  are 
excellent  on  account  of  their  weight,  and 
the  long,  sausage-shaped  bags  are  the  best, 
as  they  can  be  placed  along  the  whole 
length  of  each  side  of  an  extremity,  espe- 
cially the  leg.  Chaff  cushions  are  also 
very  good,  as  their  contents  can  be  collected  at  each  end  of  the  bag, 
which  may  then  be  wrapped  around  an  extremity  and  secured  by  a 
bandage,  cloth,  etc.  The  same  effect  was  obtained  by  the  old-fashioned 
straw  splint  (Fig.  191),  which  can  be  made  very  simply  by  vrrapping 
the  two  ends  of  a  good-sized  strip  of  cloth  around  bundles  of  straw  or 
some  similar  material ;  the  extremity  is  placed  between  two  bundles, 
where  it  can  be  secured  with  a  bandage.  Tightly  stuffed  cushions 
of  horse-hair  or  seaweed,  the  shape  of  which  cannot  be  altered,  are 
also  used. 

2.  The  Single  and  Double  Inclined  Plane. — If  it  is  desirable  to 
elevate  the  peripheral  end  of  an   extremity  either  for  inflammatory 

swelling,  simple  conges- 
tion, or  for  some  injury 
or  after  an  operation, 
it  can  be  accomplished 
very  readily  by  placing 
beneath  the  extremity 
chaff  cushions  arranged 
so  as  to  form  a  simple 
inclined  plane.  The  same  result  can  be  obtained  by  placing  under  the 
leg  an  ordinary  board  with  its  distal  end  raised,  or  by  using  Petit's 


Fig.  192. — Double  inclined  plane. 


206 


THE  SICK-BED  OF  THE   PATIENT. 


box  splint  (Fig.   193),  or  suspension, 
used  chiefly  for  the  lower  extremity. 


Fig. 


The  double  inclined  plane  is 
A  large,  wedge-shaped  cushion 
will  answer  the  purpose,  or 
a  couple  of  boards  joined 
by  a  hinge  and  fastened 
with  strings  so  as  to  main- 
tain any  desired  angle.  Es- 
march's  double  inclined 
plane,  fitted  with  lateral  re- 
tention pegs,  is  exceedingly 
useful  (Fig.  192). 

3.  Box  SpLLnts  were  used 
193.— Petit's  box  splint  for  the  leg.  a  good  deal  at  one  time  for 

fractures  of  the  leg  and 
other  injuries  below  the  knee.  Petit's  box  splint  (Fig.  193)  is  a  very 
good  one.  All  the  other  box  splints  have  been  replaced  by  modern 
splints,  particularly  those  of  plaster  of  Paris. 

-1.  Suspension. — The  old-fashioned  suspension  appliances  for  hold- 
ing the  extremity  in  proper  position  are  at  present  entii-ely  superflu- 
ous, as  we  now  combine  all  the 
various  retention  and  extension 
dressings  with  suspension.  We 
shall  return  to  this  subject  later 
in  the  description  of  the  various 
splints. 

Suspension  in  curvature  of 
the  spine,  etc.,  \vill  be  described 
in  the  text-book  on  Eegional 
Surgery.  Kauehfuss's  suspen- 
sion appliance  is  represented  in 
Fig.  218. 

The  simplest  way  of  suspend- 
ins:  an  extremitv  is  to  use  a 
framework  having  two  upright 
rods  of  wood  with  a  horizontal 
cross-piece.  For  children,  simple 
wooden  hoops  are  fastened  to  the 
bed,  and  to  these  the  extremity  is 
secured  by  a  bandage  or  strips  of 
adhesive  plaster.  I  use  an  ad- 
justable iron  frame  with  rollers  (Fig.  1941  The  cross-bar  can  be 
raised  or  lowered  to  any  convenient  height  by  means  of  the  handle  (A), 


^•^^^i^^-^^-^fr^-^^^-^^ — 3 


Fig.  194. — The  author's  suspension  apparatus. 


53.] 


SICK-BED   APPLIANCES— SPLINTS,  CUSHIONS,  ETC. 


207 


The  rope  for  exerting  the  traction  with  the  weight  ( G)  runs  over  wheels 
which  can  be  moved  to  one  side  or  the  other  and  readily  retained  at 
any  point  by  the  notches  in  the  cross-bar.  Iron  frames  which  can  be 
fastened  to  the  bed  are  very  useful. 

5.  Wire  Splints.  Wire  Gutters,  Stockings,  and  Cases. — Wire  gut- 
ter splints  (Figs.  196,  197)  are  as  simple  as  they  are  comfortable,  and 
have  supplanted  to  a  large  extent  the  contrivances  just  described. 
Wire  gutters  are  usually  made  of  wide-mesbed  wire  gauze,  padded  with 
a  thin  layer  of  horse-hair  or  small  cushions  of  cotton,  jute,  etc.  They 
are  straight,  or  bent  at  an  angle,  and  of  various  lengths  and  sizes.  As 
they  are  flexible  they  can  be  made  to  fit  the  limb  more  or  less  accu- 
rately by  means  of  straps.     Roser's  contrivance  is  very  useful.     It  con- 


FlG. 


196. —  Wire  gutter  for  the 
upper  extremity. 


Fig.  195. — Suspended  upper  extremity;  inter- 
rupted plaster  dressing  with  splints  and 
telegraph  wire. 


Fig.  197.— Wire  gutter  for  the 
lower  extremity. 


sists  of  a  wire  gutter  for  the  entire  lower  extremity,  and  is  made  in 
two  or  three  different  parts,  which  can  be  telescoped  together  to  any 
desired  extent  and  fixed  in  the  proper  position  with  strings.  For  im- 
mobilising both  lower  extremities,  together  with  the  pelvis — for  exam- 
ple, in  fractures  of  the  latter.  Bonnet's  wire  stockings  were  once  used. 
Bonnet  has  also  invented  an  excellent  wire  frame  or  case  for  inclosing 
the  whole  body  in  fractures  of  the  vertebrje. 

6.  Splints  and  Splint  Bandages, — Splints  are  generally  employed  in 
the  treatment  of  fractures  and  in  making  dressings  which  harden  after 
their  application,  as  well  as  ordinary  antiseptic  dressings. 

Splints  are  made  in  an  immense  variety  of  shapes,  either  resembling 
more  or  less  deep  gutters,  or  only  shghtly  concave  or  entirely  fiat ;  they 
may  be  straight,  or  bent  at  a  right,  acute,  or  obtuse  angle.  Splints  are 
made  of  wood,  papier-mache,  metal,  silica,  felt,  plaster,  etc. 

Wooden  Splints. — The  stiff,  unyielding  wooden  splints  are  usually 
made  from  the  coarse  heart  wood  of  the  tree ;  they  are  flat  or  shghtly 
concave,  or  fashioned  to  fit  the  contour  of  a  particular  portion  of  the 
body,  and  they  may  be  straight  or  bent  at  an  angle.     Fenestrse  are 


208 


THE   SICK-BED  OF   THE    PATIENT. 


usually  cut  in  them  to  correspond  to  any  projecting  portions  of  the 
body,  such  as  the  internal  condyle  of  the  humerus  at  the  elbow,  or  the 
malleoli  at  the  ankle,  and  thus  the  skin  over  these  points  is  preserved 
from  an  undue  amount  of  pressure,  which  might  cause  it  to  become 
gangrenous.     In  Fig.  198  are  represented  various  kinds  of  splints  for 


Fig.  198. — Splints  for  the  arm  and  hand. 


the  upper  extremity ;  they  are  straight,  or  bent  at  an  acute  or  obtuse 
angle,  and  made  of  wood  or  papier-mache.  The  splints  (c  tof)  are 
padded  with  cotton,  jute,  or  tow,  and  then  covered  with  rubber  tissue, 
the  ends  of  which  are  stuck  to  the  back  of  the  splint  with  chloroform. 
These  splints  are  used  almost  exclusively  for  inflammation,  injuries, 
and  fractures  of  the  fingers,  hand,  and  forearm.  The  splint  d  is  some- 
what modified  from  Nelaton's  pistol  splint  for  fracture  of  the  radius. 

Wooden  arm  splints  for  the  entire  upper  extremity  can  be  made 
like  the  models  represented  in  Fig.  198,  e  ovf.    Esmarch's  arm  splints 


Fig.  199. — Esmarch's  splint  for  resections  of 
the  elbow. 


Fig.  200. — Volkmann's  supination  splint. 


(Fig.  199)  are  also  very  useful — for  example,  after  resection  of  the 
elbow-joint ;  Yolkmann's  supination  splint  is  likewise  good,  and  ena- 
bles the  arm  to  be  immobilised  in  a  position  between  pronation  and 
supination  (Fig.  200). 


53.] 


SICK-BED  APPLIANCES— SPLINTS,  CUSHIONS,  ETC. 


209 


Esmarch's  double  splint  (Fig.  201)  is  exceedingly  good  for  a  resected 
el  bow- joint.  It  consists  of  two  parts  upon  which  the  arm  rests,  the 
upper  portion  being  joined 
to  the  lower  by  a  steel 
bow  (Fig.  201,  ^>j.  If  it  is 
■desirable  to  place  the  fore- 
arm and  hand  in  a  verti- 
<^al  position,  in  cases  of 
acute  inflammation,  in  or- 
der to  lessen  the  conges- 
tion, Yolkmann's  suspen- 
sion splint  is  very  useful 
(Fig.  202) ;  the  ring  at  the 
extremity  of  the  splint  is 
employed  for  suspending 
it  in  the  vertical  position  ; 
but  an  arrangement  of 
■cushions  and  bandages  will 
■ordinarily  be  found  suffi- 
•cient  for  securing  the  fore- 
arm in  position. 

The  two  excellent 
splints  of  Esmarch  and 
Lister  for  resection  of  the 
wrist   are   represented   in 

Fig.  203,  «,  h,  and  Fig.  204.     Esmarch's  bow  splint  is  easily  made 
from  a  piece  of  wood  or  sheet  iron.     The  wooden  splints  for  the  lower 

extremity  have  been  mostly  supplanted 
by  metallic  splints.  Fig.  205  shows 
Yolkmann's  wooden  dorsal  splint,  and 
Fig.  206  Esmarch's  wooden  splint  for 
a  resected  ankle.  It  is  applied  to  the 
posterior  surface  of  the  leg,  which  is 
then  encased  in  plaster  of  Paris  and 
suspended  by  telegraph  wire. 

Pliable  Wooden  Splints. — In  addi- 
tion to  these  stiff  wooden  splints  there 
have  been  recommended  splints  made 
of  wood  which  is  capable  of  bending, 
but  they  have  not  been  received  with 
as  much  favour  as  they  deserve.     They  are  always  well  suited  for 
making  an  impromptu  dressing,  especially  in  transporting  patients  to 
15 


Fig.  201. — Esmarch's  double  splint  for  resections  of  the 
elbow. 


Pig.  202. — Volkmaun's  suspension  splint. 


210 


THE  SICK-BED   OF   THE   PATIENT. 


the  hospital.     Even  in  ancient  times,  according  to  the  assertion  of 
E.   Fischer,  splints  were  manufactured  from  wood  which  could  be 

bent  into  any  desired  shape.  For 
this  purpose  there  were  used  the 
stem  of  the  Spanish  broom,  strips 
of  wood  cut  very  thin,  pieces  of 
veneering,  green    twigs,  palmetto 


Fig.  203. — Esmarch's  interrupted  splint  for  Fig.  204. — Lister's  splint  for  resections  of  the 

resectiojis  of  the  wrist.  wrist. 


leaves,  and  the  bark  of  trees.  According  to  the  same  authority,  the 
Turks  use  moulded  wooden  splints  made  of  the  fibrous  portions  of 
palmetto  leaves  sewed  to  thin  leather,  thus  obtaining  a  material  which 
can  be  applied  to  an  injured  limb  either  circularly  or  in  the  form  of  a 


Fig.   205. — Volkmann's  dorsal  splint  (for 
suspension). 


Fig.  206. — Esmarch's  wooden  splint  for 
resections  of  the  ankle. 


gutter.  Martini  and  Gooch  glue  narrow,  thin  strips  of  wood  taken 
from  the  linden  tree  close  together  upon  soft  leather,  and  in  this  way 
a  splint  can  be  made  which  is  an  excellent  temporary  dressing  for  a 

fracture,  particularly  of  the  lower 
extremity.  Esmarch's  splint  ma- 
terial, which  can  be  cut  into  any 
required  size,  is  very  similar  to  this 
(Fig.  207).  It  consists  of  strips  of 
wood  three  centimetres  wide  and 
one  and  a  half  centimetre  thick, 
which  are  glued  between  two  layers 
of  cotton  cloth.  Herzenstein  ad- 
vises that  splints  be  made  after  the  fashion  of  the  ordinary  trellis  work 
used  for  supporting  vines.  Reeds,  willow  withes,  and  straw  made  into 
mats  have  also  been  recommended  as  splints.     Thin,  pliable  strips  of 


Fig.  207. — Esmarch's  material  for  making 
splints. 


§53.]  SICK-BED   APPLIANCES— SPLINTS,  CUSHIONS,  ETC.  211 

wood  about  three  to  four  centimetres  wide  make  a  very  good  material 
for  splints  when  combined  with  plaster  bandages,  and  are  also  very 
useful  for  immobilising  a  joint  after  an  antiseptic  dressing  has  been 
applied. 

Wood  Dressings. — Waltuch  recommends  wood  dressings  made  of  shav- 
ings, 4.5  centimetres  wide  and  0.5  to  1  millimetre  thick,  and  any  desired 
length,  which  are  prepared  by  planing  pine  planks  in  a  particular  way.  The 
wood  shavings  roll  up  spontaneously  like  a  bandage,  are  more  easily  handled 
than  thin  board  splints,  and  much  cheaper  than  the  latter.  This  wood  dress- 
ing, consisting  of  shavings  bound  together  with  glue,  is  suitable  for  corsets, 
for  encasing  a  limb,  etc.     (Wien.  klin.  Wochensch.,  1888,  No.  10.) 

Papier-mache  Splints. — Splints  made  of  stout  papier-mache,  about 
three  millimetres  thick,  are  very  frequently  employed  for  immobilis- 
ing purposes.  These  splints  are  usually  made  with  flat  edges,  which 
may  be  bent  into  any  required  shape,  or  else  flat  pieces  are  used  of 
varying  widths.  After  dipping  this  material  in  warm  water  just 
before  it  is  to  be  used,  it  becomes  soft,  and  can  be  readily  made  to  flt 
any  part  of  the  body  when  fastened  on  with  a  bandage.  The  small 
papier-mache  splints  are  chiefly  used  for  strengthening  dressings  in 
which  starch  is  employed. 

Metal  Splints. — Metal  splints  are  generally  made  of  iron,  sheet  iron, 
tin,  zinc,  telegraph  wire,  wire  gauze,  etc.,  and  may  be  stiff  and  unyield- 
ing or  capable  of  being  bent  into  any  shape.  Yolkmann's  sheet-iron 
splint  (Fig.  208)  is  exceedingly 
good,  and  in  very  general  use 
for  the  lower  extremity.  It  is 
a  good  plan  to  make  this  of  two 
parts — an  upper  and  lower — for 
lengthening  and  shortening  the 

T     ,  ^  „„    „     „..^^,-,^<-      Fig.  208. — Volkmann's  sheet-iron  splint  for  ttie 

splmt     any     necessary    amount  lower  extremity. 

(Miigge).     Metal  splints   which 

are  capable  of  being  bent  into  any  shape  are  best  made  of  telegraph 
wire,  tin,  zinc,  or  galvanised  iron.  Flat  splints,  made  of  thin  tin  plate, 
have  been  recommended  by  Solomon  and  introduced  in  the  Danish 
army  ;  they  are  thirty-five  centimetres  long  and  ten  centimetres  wide, 
having  at  one  end  two  small,  three-pronged  projections,  which  are 
hook-shaped  and  notched,  and  at  the  other  two  clefts,  into  which  the 
projections  are  inserted  and  secured,  thus  rendering  it  possible  to  make 
a  splint  of  any  desired  length.  Thin  galvanised  iron  which  is  capable 
of  being  cut  with  shears  has  been  recommended,  especially  by  Schon 
and  Weissbach,  as  a  material  suitable  for  splints.  Schon  gives  direc- 
tions for  making  excellent  splints  in  a  very  short  time  from  this  sub- 


212 


TUE  SICK-BED   OF   THE   PATIENT. 


stance,  and  liinge  joints,  fenestrse,  and  interrupted  spaces  can  be 
inserted.  In  Fig.  209  is  represented  a  simple  way  of  making  a  gutter 
splint  for  the  arm  and  leg. 

The  gutter  splint  for  the  arm  (Fig.  209)  is  made  by  cutting  out  a  splint 
of  the  desired  size  and  bending  it  on  its  long  axis  so  as  to  form  a  shallow 
groove,   and  then  transversely   so  as  to  make  an   obtuse  or  right  angle. 


T 


j7 


Fig.  209. 


-Pattern  for  making  a  tin  gutter 
for  the  arm  (Schon). 


C^     a 

72 

*    ^ 

/ 

\ 

V          "^ 

iJ2               7 

i     J 

Fig.  210. — Pattern  for  making  a  tin  gutter 
for  the  leg  (Schon). 


Strings  are  passed  through  the  punctures  at  a  a,  and  tied  to  maintain  the 
splint  at  the  proper  angle.  The  gutter  splint  for  the  leg  is  cut  from  galva- 
nised sheet  iron,  as  represented  in  Fig.  210 ;  it  is  then  bent  on  its  long  axis 
into  a  half  circle,  and  the  foot-piece  is  formed  by  bringing  the  lateral  parts 
a  a  around  behind  the  middle  part,  and  retaining  them  in  this  position  by 
strings  oi-  wires. 

Aluminium  SpHnts. — Stendel  has  devised  a  pair  of  shears  for  cutting 
akiniiniuui  plate  into  the  proper  shape.  The  splints  of  aluminium  have 
the  advantage  of  being  cheap,  light,  and  pliable. 

Wire  Splints,  made  from  properly  bent  telegraph  wire  or  from  wire 
netting,  are  used  a  good  deal.  Telegraph  wire  is  chiefly  used  at  pres- 
ent for  making  suspension  splints,  and  in  the  preparation  of  the  inter- 
rupted plaster  splint  (Figs.  221-223).  One  of  the  best-known  kinds 
of  wire  splint  is  Smith's  (Fig.  211),  which  is  especially  well  suited  for 
the  treatment  of  compound  fractures  of  the  lower  extremity.  It  is 
made  of  two  nearly  parallel  bars  joined  at  their  extremities  and  in  the 


Fig.  211. — Smith's  anterior  wire  splint. 


Fig.  212. — Esmarch's  splint  for  the  arm, 
made  out  of  telegraph  wire. 


intervening  space  by  from  two  to  four  movable  wire  arches  or  hoops, 
to  which  are  attached  the  ropes  for  suspending  the  splint.  At  three 
places — namely,  over  the  ankle,  knee,  and  hip  joints — it  is  slightly 
bent,  and  is  then  applied  to  the  anterior  surface  of  the  limb,  to  which 
it  is  secured  generally  by  a  plaster  bandage. 


53.] 


SICK-BED  APPLIANCES— SPLINTS,  CUSHIONS,  ETC. 


213 


Esmarch  has  constructed  a  splint  (Fig.  212j  of  telegraph  wire  for 
the  upper  extremity,  which  approaches  the  character  of  the  splints 
made  of  wire  gauze  gutters  for  the 
upper  and  lower  extremities  (Figs. 
196, 197).  Woven  wire  is  also  used 
for  making  splints  which  can  be  bent 
into  different  shapes.  Esmarch  has 
recommended  the  use  of  long  strips 
of  wire  lattice  for  splints,  and  from 
this  material  it  is  very  easy  to  make 
a  splint  similar  to  Bonnet's  stocking. 
Cramer's  lattice-work  splint,  made 
of  iron  wire  tinned  over,  is  exceed- 
ingly good  both  for  ordinary  prac- 
tice and  for  army  surgery.  These 
splints  can  be  bent  into  any  shape, 
and  can  be  made  to  fit  over  any 
dressing  or  any  part  of  the  body 
(Fig.  213),  and  they  can  be  length- 
ened by  fastening  one  or  more  to- 
gether. By  taking  out  some  of  the 
cross-pieces  and  bending  the  lateral 
bars  the  splint  can  be  made  inter- 
rupted, or  can  be  bent  at  any  angle 
(Fig.  213,  d^  e).  Neuber  has  recom- 
mended splints  made  of  glass  (Figs. 
214,  215),  as  particularly  good  for 
cases  where  an  antiseptic  dressing 
is  left  in  place  for  a  considerable 
time.  They  are  transparent,  and  permit  all  parts  of  the  dressing  to  be 
inspected  without  disturbing  the  limb. 

Plastic  Splints.— Moulded  splints  are  prepared  by  wetting  or  heating 
the  material  of  which  they  consist,  and  when  it  has  become  soft  and 


Fig. 


213. — Pliable  splints  made  of  iron  wire 
tinned  over  (Cramer). 


Fig.  214. — Neuber's  glass  splint  for  the 
upper  extremity. 


Fig.  215.- 


-Neuber's  glass  splint  for  the 
lower  extremity. 


plastic  it  is  made  to  fit  snugly  over  some  particular  portion  of  the  body 
by  the  aid  of  a  roller  bandage.     After  the  material  becomes  dry  or 


214  THE  SICK-BED   OF   THE   PATIENT. 

cold,  whichever  the  case  maj  be,  a  hard,  unyieldinsf  splint  results 
which  fits  very  closely. 

Papier-mache. — In  the  pi-eparation  of  these  splints  ordinary  papier- 
mache  can  be  used,  though  it  possesses  only  a  moderate  amount  of 
firmness  when  dry.  The  prepared  papier-mache  of  P.  Bnins  is  better, 
and  consists  of  ordinary  papier-mache  which  has  been  impregnated 
with  some  hardening  substance,  generally  shellac.  "When  this  prepara- 
tion is  warmed  in  a  hot  oven,  or  wet  in  boiling  water,  it  becomes  soft, 
and  capable  of  being  moulded  into  any  shape  in  a  very  few  minutes, 
and  subsequently  becomes  as  hard  as  wood  in  from  five  to  ten  minutes. 

Plastic  Felt. — Pliable  felt  can  be  used  in  a  similar  manner,  and  P. 
Bruns  describes  its  preparation  as  follows :  A  sheet  of  ordinary  felt, 
from  five  to  eight  millimetres  thick,  is  soaked  in  a  solution  consisting 
of  one  part  shellac  to  one  and  a  half  parts  of  alcohol  until  it  has  be- 
come completely  saturated,  or  until  the  felt  will  absorb  no  more  of  the 
solution.  (It  takes  up  about  four  times  its  own  weight.)  It  is  then 
allowed  to  dry,  and  from  this  material  excellent  splints  can  be  made  in 
the  shape  of  flat  strips,  or  gutters,  or  cases.  After  cutting  the  piece 
of  plastic  felt  into  the  proper  shape,  it  is  dipped  into  water  which  is 
almost  boiling,  or  stroked  with  a  hot  flat-iron  or  laid  on  a  hot  stove-lid, 
which  causes  it  to  become  as  soft  as  any  ordinary  unimpregnated  felt. 
The  softened  felt  is  then  applied  \vith  a  roller  bandage  to  the  limb, 
which  has  been  previously  covered  with  a  bandage  or  with  cotton,  and 
in  a  short  time  this  splint  becomes  as  hard  as  a  board.  F.  Schwarz  has 
used  moulded  felt  in  Billroth's  clinic,  as  a  substitute  for  more  expen- 
sive and  complicated  contrivances,  with  the  very  best  results  (Wien. 
med.  Wochensch.,  1886,  Wo.  37).  Splints  of  stiff  black  caoutchouc  are 
very  serviceable.  They  can  be  softened  in  hot  water  and  given  any 
desired  form. 

Gutta-percha. — Gutta-percha  can  be  used  in  a  similar  manner  for 
making  straight,  gutter,  or  case  splints.  Gutta-percha,  or  the  dried  sap 
of  an  East  Indian  tree  {Isonandra  gutta,  Sapotacee),  was  introduced  in 
Europe  in  18-13,  and  was  first  used  for  treating  fractures  in  England  in 
1846,  though  it  had  been  employed  for  this  purpose  in  Borneo  a  long 
time  previously.  When  gutta-percha  is  warmed  in  hot  water  it  becomes 
soft  and  capable  of  receiving  any  shape,  and  then  hardens  when  it  cools 
off,  in  about  fifteen  minutes.  For  making  straight,  gutter,  or  case 
splints  of  gutta-percha,  sheets  of  this  material  are  cut  into  the  proper 
form  and  softened  by  immersion  in  water  at  a  temperature  of  T5°  to 
85°  C.  The  splint  is  then  allowed  to  cool  off  slightly,  and  after  being 
modelled  into  the  shape  required  to  fit  the  particular  extremity,  whicli 
has  been  previously  encased  in  a  flannel  bandage,  it  is  kept  in  place  by 


§  53.]  SICK-BED  APPLIANCES— SPLINTS,  CUSHIONS,  ETC.  215 

a,  wet  roller  bandage.  By  gluing  together  the  edges  of  two  gutters  a 
circular  splint  maj  be  made.  Gutta-percha  is  not  affected  by  water, 
blood,  pus,  or  urine,  but  it  is  expensive,  and  on  this  account  has  not 
been  very  generally  used. 

Leather. — Ordinary  leather  is  an  excellent  material  for  making 
straight  or  case  splints ;  it  should  be  soaked  in  water  and  apphed  to  the 
limb  with  a  roller  bandage  while  in  a  wet  condition,  when  it  is  capable 
of  being  moulded. 

Cellulose  Splints. — R.  de  Fischer  has  advised  the  use  of  a  hardening' 
material  for  splints  made  of  cellulose.  Thick  flat  plates  of  cellulose  are 
manufactured  for  this  purpose  having  the  outline  of  the  different  limbs,  and 
strengthened  on  one  side  with  water  glass.  This  side  of  the  splint  is  then, 
before  use,  painted  over  with  nearly  boiling  water,  which  causes  the  material 
to  become  immediately  soft  and  pliable.  The  splint  is  applied  wet  side  out, 
and  fastened  in  position  with  gauze  bandages  which  have  been  saturated  with 
■cold  water.  These  splints  can  be  strengthened  by  impregnating  them  with 
water  glass  on  both  sides.  They  are  said  to  possess  the  advantage  of  simplic- 
ity, raj)idity  in  hardening,  lightness  and  durability,  and,  furthermore,  cost 
very  little.  They  are  manufactured  by  the  apothecary  in  Triest,  Karl  Zanetti. 
Landerer,  Kirch,  and  others  recommend  celluloid  splints.  They  are  made 
of  celluloid  bandages,  which  are  gauze  bandages  impregnated  with  a  solu- 
tion of  celluloid  in  aceton  (1  to  3).  One  disadvantage  is  that  the  material  is 
inflammable. 

Extension  Splints. — Before  the  introduction  of  extension  by  weight, 
extension  splints  were  employed,  and  they  will  be  referred  to  in  their 
proper  place. 

Articulated  Splints. — Jointed  splints  are  those  consisting  of  two  or 
more  ordinary  splints  united  by  a  joint  or  some  material  capable  of 
bending,  such  as  caoutchouc,  cloth,  leather,  etc.  A  jointed  splint  can 
be  fastened  at  any  desired 
angle,  or  can  be  left  mov- 
able, permitting  free  mo- 
tion in  the  extremity  to 
which  it  is  applied. 

There  is  a  great  variety 
■of  these  articulated  splints, 
the  best  one  probably  be- 

I'-no-  TTmnp'«  (  V^a-  9,1  fi^  FiG.  216.— Heine's  disjointable  articulated  splint  for  the 
lUg      XlfcJiut;  b      V-L  ^S-      ^-^"Jj  upper  extremity. 

though  Bidder,  Liicke,  and 

•others  have  constructed  very  excellent  splints.  These  articulated  splints 
can  be  used  for  exerting  a  gradual  extension  on  contracted  joints,  for 
overcoming  contractures  of  the  muscles  and  soft  parts,  and  for  the 
after-treatment  of  resected  joints  as  a  supporting  apparatus. 


216 


THE  SICK-BED   OF   THE   PATIENT. 


Stillmaiin  Las  also  recommended  an  excellent  adjustable  brace,, 
which  permits  motion  in  the  joint  to  which  it  is  appUed,  and  which 
can  be  readilj  included  in  a  plaster  dressing  (Figs.  217,  218). 

Improvised  Dressings  of  the  Battle-field. — In  times  of  war  it  may 
become  necessary  to  improvise  dressings  and  splints  out  of  whatever 
materials  may  be  at  hand.     J.  Port  has  written  a  book  on  this  subject 


Fig.   217. — Adjustable  clamp  apparatus. 


Fig.  218. — Clamp  apparatus  provided 
with  a  joint. 


(Stuttgart,  Ferd.  Enke,  1892),  in  which  are  a  number  of  illustrations 
and  descriptions  of  materials  which  can  be  used  as  surgical  dressings. 

Apparatus  for  Home  Gymnastics. — Brief  mention  should  be  made  in 
this  place  of  the  different  kinds  of  apparatus  used  for  gymnastic  pur- 
poses which  should  always  be  found  in  every  hospital.  It  would  take 
too  much  space  to  describe  them  except  in  a  very  general  way.  The 
machines  invented  by  Zander,  of  Stockholm,  aiford  many  kinds  of 
gymnastic  exercise  which  are  exceedingly  useful  in  some  cases,  and 
their  place  cannot  be  supplied  by  either  massage  or  passive  motion. 
N^ew  and  simplified  apparatus  are  constantly  being  constructed  for 
carrying  out  active,  passive,  local,  and  general  movements.  These 
gymnastic  apparatus  are  coming  more  and  more  into  use  in  hosjDital 
and  private  practice. 


CHAPTEE   Y. 

THE  APPLICATION  OF  IMMOBILISING  DEESSINGS  MADE  OF  MATERIALS  WHICH 
GRADUALLY  HARDEN. THE  APPLICATION  OF  EXTENSION  APPARATUS. 

Plaster  dressings. — Dressings  of  tripolith,  starch  paste,  water  glass,  gutta-percha,  and 
felt. — The  methods  of  employing  extension. 

§  54.  Immobilisation  Dressings  of  Hardening  Substances. — Dressings 
for  producing  immobilisation  are  used  for  fractures,  inflammations  in 
joints,  and  after  many  operations — for  example,  in  the  after-treatment 
of  resections  and  osteotomies,  etc. ;  they  serve  the  purpose  of  prevent- 
ing movement  in  the  part  of  the  body  under  treatment.  Even  in 
ancient  times  attempts  were  made  to  form  immobilisation  dressings 
from  substances  which  would  subsequently  harden,  but  the  methods 
were  imperfect.  To  Larrey,  the  distinguished  army  surgeon  of  IS^a- 
poleon  I.,  belongs  the  honour  of  having  generally  introduced  those 
immobihsing  dressings  which  were  applied  in  the  soft  state  and  then 
allowed  to  harden.  Larrey  soaked  the  dressings  for  twenty-four  to 
thirty-six  hours  in  a  mixture  made  of  albumen,  liquor  plumbi  subace- 
tatis,  and  spirits  of  camphor.  This  somewhat  tedious  procedure  was 
supplanted  by  the  starch  dressing  invented  by  Seutin  in  1834.  As  the 
starch  dressing  took  a  long  time  to  harden,  attention  was  directed  to 
some  more  rapidly  hardening  material,  and  gypsum  was  taken  up,  a 
substance  which  had  been  employed  by  the  Arabian  physicians.  The 
honour  of  introducing  the  gypsum  dressing  and  the  methods  of  apply- 
ing it  is  due  to  the  two  Dutch  physicians,  Mathysen  and  Yan  der  Loo. 
IS'umbers  of  other  hardening  substances,  such  as  water  glass,  tripolith, 
etc.,  have  also  been  used  in  the  same  way. 

The  Plaster-of-Paris  Dressing. — Among  all  the  materials  employed 
for  making  an  immobilising  dressing  there  is  none  better  than  gypsum, 
possessing,  as  it  does,  the  power  of  rapidly  becoming  hard.  Gypsum, 
or  plaster  of  Paris,  is  hydrated  sulphate  of  calcium  (CaSOi-f-  SHjO). 
The  gypsum  used  in  dressings  is  burned  or  dehydrated,  and  after  mix- 
ing it  with  water  it  hardens  in  a  few  minutes  to  a  solid  mass,  forming 
with  water  a  firm  chemical  combination.     The  plaster  dressing  can  be 

217 


218  THE   APPLICATION  OF   IMMOBILISING   LKESSINGS. 

applied  in  many  different  ways,  the  best  being  in  the  form  of  plaster 
bandages.  For  this  purpose  bandages,  preferably  of  gauze,  are  im- 
pregnated with  dry  gypsum  powder  by  roiling  them  in  the  latter  and 
working  it  into  the  meshes  of  the  gauze.  Soft  mnll  bandages  can  also 
be  treated  in  the  same  way.  The  application  of  the  gypsum  dressing  is 
begun  by  smoothly  enveloping  the  particular  portion  of  the  body  with 
a  soft  mull  or  flannel  bandage,  or  with  a  thin  laj^er  of  cotton,  over 
which  is  placed  a  soft  mull  bandage.  In  emergency  cases  the  extrem- 
ity may  merely  be  greased  with  oil,  lard,  or  vaseline,  to  prevent  the 
plaster  from  sticking  to  the  hairs  ;  bony  projections  should  be  covered 
with  a  little  cotton,  to  avoid  pressure  at  these  points ;  and,  above  all, 
one  must  be  careful  to  apply  the  bandages  loosely,  so  that  after  drying 
they  do  not  become  too  tight.  Cotton  hose  can  also  be  used  beneath 
the  gypsum;  it  is  drawn  over  the  extremity  like  tights;  it  is  cheap, 
and  fits  exceedingly  well  without  forming  wrinkles.  When  necessary, 
two  or  three  layers  of  this  material  may  be  put  on  over  each  other. 
The  roller  gypsum  bandages  are  then  allowed  to  soak  in  water  about  a 
quarter  of  a  minute,  or  until  no  more  air  bubbles  are  given  off.  The 
bandage  is  then  squeezed  dry  and  applied  to  the  part  in  question  as 
loosely  as  possible.  It  should  never  be  drawn  tight,  as  this  will  cause 
the  bandage  to  become  too  narrow,  and  may  subsequently  impede  the 
circulation  in  the  limb.'  There  is  no  need  of  making  a  reverse  with 
the  gypsum  bandage,  as  a  few  wrinkles  do  no  harm  and  can  be  smoothed 
out  by  rubbing  the  bandage  with  the  hand,  and  thus  causing  the  dress- 
ing to  conform  accurately  to  the  shape  of  the  limb.  After  about  three 
or  four  layers  of  gypsum  bandage  have  been  applied,  a  thin  layer  of 
gypsum  paste  can  be  added ;  it  is  made  by  mixing  together  gypsum 
powder  and  water  in  about  equal  proportions.  This  layer  is  spread  on 
and  smoothed  over  with  the  palm  of  the  hand,  the  smoothing  process 
being  continued  until  the  dressing  looks  as  though  made  in  one  piece. 
The  gypsum  paste  should  not  be  put  on  too  thick,  for  fear  of  making 
the  dressing  very  heavy,  and  I  frequently  do  not  use  it  at  all.  Plenty 
of  bandage  and  not  too  much  plaster  is  my  maxim.  The  edges  of  the 
dressing  are  best  treated  by  turning  up  the  projecting  underlying 
material  (cotton  or  bandages)  like  a  cuff  and  securing  it  to  the  outer 
surface  of  the  splint  with  a  turn  of  the  plaster  bandage  or  a  little  of 
the  paste. 

Even  while  the  bandages  or  outer  layer  of  plaster  paste  are  being 
smoothed  down  with  the  hand,  it  will  be  noticed  that  the  dressing  has 
become  firmer.  In  the  next  few  minutes  it  becomes  noticeably  warm 
and  at  the  same  time  perfectly  hard,  but  not  till  two  or  three  hours 
later  will  the  dressing  be  completely  dry.     By  the  addition  of  some 


i  54.]    IMMOBILISATION  DRESSINGS  OF  HARDENING  SUBSTANCES.    219 


Fig.  219.— Thin  strips  of  wood  used  for 
strengthening  a  plaster-of-Paris  splint. 


Fig.  220. — Fenestrated  plaster  splint. 


crystalline  substance,  like  chloride  of  sodium  or  alum,  the  hardening 
of  the  gypsum  can  be  accelerated.  If  it  is  desired  to  make  the  plaster 
dressing  water-tight,  its  external  sur- 
face can  be  painted  with  a  solution  of 
resin  in  ether — one  to  four  (Mitscher- 
lich) — or  a  water-glass  bandage  may 
be  placed  over  the  gypsum  ;  this  latter 
method  is  the  best.  It  makes  the  gyp- 
sum dressing,  particularly  when  ap- 
plied to  children,  exceedingly  durable. 
For  increasing  the  strength  of  the  plaster  dressing  the  latter  is  often 
made  to  include  thin,  pliable  strips  of  wood  (Fig.  219),  or  splints  made 

of  papier-mache,  wood, 
zinc,  or  wire.  If  it  is 
not  desirable  to  cover  in 
some  portion  of  the  body 
by  the  plaster  dressing 
on  account  of  wounds, 
fistulse,  etc.,  a  fenestrum 
(Fig.  220)  can  be  cut  out 
over  this  portion,  the  location  of  which  may  be  previously  indicated  by 
placing  over  it  a  piece  of  cotton  or  a  flat  disk  having  a  projecting 
nail.  The  edges  of  the  fenes- 
trum can  be  smoothed  off  with 
a  little  plaster  paste  or  asphalt- 
varnish,  to  prevent  fluids  such 
as  pus  from  gaining  access  to  the 
under  surface  of  the  dressing. 
When  a  considerable  portion  of 
an  extremity,  such  as  the  knee- 

or  elbow-joint,  is  to  be  left  out  of  the  splint,  two  plaster  cases  should 

be  apj)lied,  one,  for  example,  to 
the  thigh,  the  other  to  the  leg, 
joined  together  by  an  iron  rod, 
which  can  also  be  covered  with 
plaster  (Fig.  221) ;  telegraph  mre 
can  be  used  in  the  same  manner. 
Under  other  conditions,  when, 
for  instance,  one  wishes  at  the 
same  time  to  suspend  the  extrem- 
ity, another  plan  is  carried  out  which  is  represented  in  Figs.  222  and 
223.     Two  plaster  cases  are  applied  to  the  extremity  while  it  lies  upon 


Fig.  221. 


-Interrupted  plaster  splint  (for  the 
knee). 


Fig.  222. — Interrupted  plaster  splint  suspended 
(upper  extremity). 


220 


THE  APPLICATION   OF  IMMOBILISING    DRESSINGS. 


a  suitable  splint,  and  a  piece  of  telegraph  wire,  having  been  bent  into 
proper  shape,  connects  the  two  separate  bandages  on  the  dorsal  surface 

of  the  limb  (see  Figs.  234,  235, 
236).  In  the  same  way  two  plas- 
ter cuffs  can  be  provided  with  a 
hinge  so  as  to  form  a  joint, 
which  is  useful  in  the  after- 
treatment  of  a  resected  elbow. 


Fig.  223.- 


-Interrupted  piaster  splint,  suspended 
(lower  extremity j. 


Gradual  stretching  of  Contract- 
ed Joints  by  the  Plaster  Dressing.— 

Tlie  plaster  dressing  cau  also  be 
used  for  gradual  extension  of  contracted  joints.  A  plaster  ease  is  applied  to 
the  lower  extremity  and  an  oval-shaped  feuestrum  cut  over  the  region  of 
the  anterior  surface  of  the  knee,  and  at  the  same  time  the  splint  is  cut 
behind  transversely  across  the  popliteal  space.  Day  by  day  continually 
larger  pieces  of  cork  are  then  wedged  into  the  posterior  line  of  division  in 
the  splint,  and  thus  the  knee-joint  is  gradually  extended. 

Gypsum  Dressing  combined  with,  an  Antiseptic  Dressing.— The  great 
advances  in  modern  aseptic  surgery  render  possible  the  frequent  combina- 
tion of  plaster  with  antiseptic  dressings.  After  osteotomy,  for  instance,  of 
the  tibia,  we  cover  the  open  wound  with  an  aseptic  protective  dressing  and 
then  apply  over  this  a  plaster  splint,  which  is  left  undisturbed  till  the  wound 
has  healed,  or  from  four  to  six  weeks. 
We  often  adopt  a  similar  practice 
in  the  after-treatment  of  resected 
joints,  allowing  the  wound  to  remain 


Fig.  224.— Plaster  splint. 


Fig.  225. — Case  for  the  lower  extremity,  with 
straps,  buckles,  and  a  hinge-joint  on  the 
opposite  side. 


partially  open.  In  other  cases  of  joint  resection  the  plaster  bandages  are  not 
placed  over  the  antiseptic  protective  dressing  till  about  three  to  five  days 
after  the  opei'ation,  when  the  drains  ai'e  taken  out.  In  compound  fractures 
the  plaster  splint  is  combined  with  the  antiseptic  dressing  at'^ihe  earliest  pos- 
sible moment.  Bergmann's  and  Eeyher's  experiences  show  that  gypsum 
dressings  will  become  of  the  greatest  use  in  army  surgery.  These  surgeons 
obtained  most  excellent  results,  during  the  Russo-Turkish  war,  from  com- 
bined antiseptic  and  plaster  dressings  for  the  treatment  of  gunshot  wounds  of 
bone.  In  addition  to  the  plaster-bandage  dressing,  as  it  is  ordinarily  de- 
scribed, mention  should  be  made  of  the  following  modifications  : 

Modifications  of  the  Gypsum  Dressing.— Compresses,  pieces  of  cloth,  or 
parts  of  the  patient's  clothing,  may  be  dipped  in  plaster  paste  and  either  laid 
around  an  extremity  or  fastened  on  with  bandages  after  previously  envelop- 
ing the  limb  in  some  buffer  dressing.  These  gypsum  cataplasms  are  highly 
recommended  by  Pirogoff,  Adelmann,  Szymanowski  and  others  for  making  a 


§  54.]    IMMOBILISATION  DEBSSINGS  OF  HARDENING  SUBSTANCES.    221 

hasty  dressing  to  sufl&ce  during  transportation  of  the  patient.  Strands  of  hemp 
may  be  dipped  in  plaster  paste,  fitted  to  the  extremity,  and  secured  with  a  dry 
gauze  bandage.  Other  materials  can  be  soaked  in  plaster  and  used  as  splints 
— e.  g.,  strips  of  cotton  cloth,  muslin,  felt,  oakum,  etc.  Cotton  filled  with 
plaster,  or  the  plaster  plates  of  Fickert,  are  dipped  in  hot  water  and  then 
applied  to  the  limb.  They  harden  in  eight  to  ten  minutes.  Plaster  beds  for 
spondylitis  (see  Fig.  226),  and  plaster  suits  for  spondylitis  and  coxitis,  were 
quickly  made  from  the  different  materials  soaked  in  plaster.  Gypsum  pow- 
der is  also  seAved  up  in  a  sack,  and  when  soaked  in  water  it  forms  a  mass 
which  readily  becomes  moulded  to  the  limb,  and  when  dried  makes  a  splint 
which  can  easily  be  taken  off  (Zsigmondy).  By  sewing  together  two  of  these 
sacks  full  of  plaster  longitudinally  upon  one  side  and  laying  them  around 
an  extremity  and  then  wetting  them,  a  gypsum  splint  is  formed  having  the 
sewed  connection  between  the  two  bags  as  a  hinge  to  facilitate  its  removal 
from  the  limb.  The  same  result  can  be  obtained  by  sewing  together  two 
pieces  of  cloth  longitudinally,  and  putting  gypsum  powder  between  the  two 
layers.     These  are  then  applied  about  the  extremity  and  moistened  with 


Fig.  226. — "  Plaster  bed  "  with  extension  for  spondylitis  in  young  children. 


water.  In  a  similar  manner  immobilisation  appliances  can  be  made  in  two 
or  more  parts  which  can  be  fastened  on  a  limb  with  bandages  or  secured 
with  sti'aps  and  buckles  (Fig.  225).  In  this  way  most  excellent  splints  can 
be  fashioned  of  gypsum  or  other  hardening  material,  such  as  water  glass,  and 
also  many  kinds  of  supporting  apparatus  can  be  substituted  for  those  manu- 
factured by  instrument  makers. 

Auschlltz  advises  that  the  straw  splints  which  have  long  been  employed 
by  stretcher  bearers  as  a  transportation  dressing  be  soaked  in  plaster  jmste 
and  bound  on  with  a  wet  gauze  bandage. 

Back  Support. — For  the  application  of  the  plaster  dressing  to  the 
lower  extremity,  and  particularly  to  the  thigh  and  pelvis,  extension 
and  supporting  appliances  are  of  great  utility.  They  render  the  pelvis 
accessible  on  all  sides,  and  prevent  a  fractured  femur  from  becoming 
shortened.  The  simplest  form  of  pelvic  support  is  represented  in  Fig. 
142 ;  it  is  Yolkmann's  cushioned  support,  which  is  placed  under  the 
sacrum.  A  footstool  used  in  the  same  way  forms  an  excellent  back 
rest.  The  patient  is  secured  in  the  horizontal  position,  with  extension 
applied  to  the  leg  and  counter-extension  to  the  axilla. 


222 


THE   APPLICATION  OP  IMMOBILISING  DRESSINGS. 


Extension  appliances  are  sometimes  very  useful  accessories  in  ap- 
plying a  plaster  splint  to  the  thigh,  especially  if  the  fracture  is  obhque 
and  there  is  marked  shortening.  Liicke,  Heine,  and  Bruns  have  in- 
vented extension  appliances  for  this  purpose.  Pulleys  were  once  used, 
particularly  for  the  lower  extremity,  in  the  application  of  plaster 
splints.  Special  contrivances  for  extension  are,  as  a  rule,  unnecessary, 
and  the  hands  of  an  assistant  will  ordinarily  be  found  sufficient.  Por- 
tative plaster  sjDlints  are  used  a 
good  deal  for  fractures  and  dis- 
eases of  the  lower  extremity.  For 
particulars,  see  Regional  Surgery, 
Plaster  dressings  are  applied  to  the 
thorax  for  injuries  and  diseases  of 


Fig.  227. — Plaster  dressing  taking  in  the 
head,  neck,  chest,  and  pelvis  for  tuber- 
cular disease  of  the  spine. 


Fig.  228. — Plaster  dressing,  taking  in  the 
shoulder,  thorax,  and  arm  for  fractures 
of  the  upper  part  of  the  humerus. 


the  spine  (Fig.  227)  and  for  fractures  of  the  upper  end  of  the  humerus. 
For  particulars,  see  Regional  Surger3^ 

Eemoval  of  Plaster  Splints. — Plaster  splints  or  dressings  are  taken 
off  with  the  assistance  of  a  knife  made  especially  for  the  purpose  (Fig, 
230),  with  shears,  or  a  saw  (Fig.  231).  The  plaster  knife  should  be 
held  with  its  edge  somewhat  at  an  angle  to  the  splint,  so  as  to  cut  it 
obliquely  to  the  external  surface  ;  or  two  oblique  longitudinal  incisions 
are  made  in  the  plaster  forming  a  V-shaped  groove.  The  deeper 
layers  of  the  splint  should  be  cut  with  the  plaster  shears.  By  mois- 
tening the  whole  splint  with  water,  or  only  along  the  Hne  where  it  is  to 


54.]    IMMOBILISATION  DRESSINGS  OF  HARDENING  SUBSTANCES.    223 


Fig.  229.— Kuife    Fia.  230.— Shears    Fig.  231.— Plaster 
for  plaster  for  cutting  saw. 

dressing.  splints. 


be  cut,  the  cutting  process  is  made  much  easier.  After  the  plaster 
dressing  has  been  cut  through  longitudinally,  the  edges  of  the  incision 
are  pulled  apart  and  the  limb  is  lifted  ont.  Plaster  splints  which  have 
been  cut  and  taken  off  may, 
when  desired,  be  replaced 
and  used  again.  In  such 
cases  it  is  best  to  connect 
the  edges  with  plaster  paste 
or  adhesive  plaster,  over 
which  plaster  paste  is  ap- 
plied, and  thus  the  edges  of 
the  splint  are  less  likely  to 
become  separated. 

Tripolith  Dressing.— Lang- 

enbeck  has  recommended  trip- 
olith as  a  substitute  for  gypsum 
or  plaster  of  Paris.  Tripolith 
is  a  greyish,  cement-like  sub- 
stance, consisting  of  gypsum 
with  a  little  silicate  of  alumin- 
ium and  charcoal  or  coke.  The 
properties  of  tripolith  are  in  general  the  same  as  dehydrated  gypsum,  but 
tripolith,  according  to  Langenbeck,  is  somewhat  lighter  and  cheaper  than 
gypsum  ;  it  also  hardens  a  little  more  rapidly,  and  when  hard  will  not  absorb 
water.     The  tripolith  dressing  is  applied  with  bandages,  like  plaster  of  Paris. 

The  Starch  Dressing. — Starch  paste  was  recommended  by  Seutm,  in 
1834,  for  the  manufacture  of  stiff  dressings.  A  starch  dressing  is 
easily  applied,  agreeable  to  the  patient,  cheap  and  light,  but  it  has  the 
disadvantage  of  requiring  from  one  to  three  days  to  become  dry,  and 
for  this  reason  starch  dressings  have  been  supplanted  by  plaster  in  the 
treatment  of  fractures.  The  starch  bandage  is  frequently  combined 
with  pasteboard  splints  in  fracture  of  the  arm,  and  is  also  used  alone  in 
the  later  treatment  of  any  fracture. 

The  method  of  applying  the  starch  bandage  is  briefly  as  follows : 
A  padding  is  laid  on  the  skin  in  the  shape  of  a  flannel  bandage,  and 
the  bony  prominences  are  protected  from  too  much  pressure  from  the 
starch  dressing  by  a  layer  of  cotton.  A  soft  mull  bandage  is  applied 
over  the  flannel,  and  then  a  layer  of  starch  or  bookbinders'  paste  is 
spread  over  the  mull.  Several  strips  of  pasteboard  of  various  sizes  are 
rendered  soft  and  pliable  by  soaking  in  warm  water,  and  are  uicluded 
in  the  dressing  in  such  a  way  as  to  incase  the  limb,  leaving  short  inter- 
vals between  each  strip.  The  pasteboard  is  then  covered  evenly  with 
the  starch  paste,  and  over  this  is  placed  a  mull  bandage,  which  receives 


224 


THE   APPLICATION   OF   IMMOBILISING  DRESSINGS. 


another  layer  of  starch  paste.  Some  three  or  four  layers  are  enough, 
and  the  strips  of  pasteboard  can  be  used  in  a  double  layer,  especially  if 
they  are  narrow.  Finally,  a  dry  mull  bandage  is  applied  to  prevent  the 
starch  paste  from  adhering  to  the  clothes,  or  a  bandage  in  the  form  of 
a  bag  may  be  used,  as  well  as  black  silk,  to  improve  the  appearance  of 
the  dressing.  The  dressing  is  cut  open  with  a  stout  pair  of  shears, 
and  can  then  be  used  as  a  removable  splint  in  the  same  way  as  described 
for  the  plaster  splints  (Fig.  225). 

Cotton-Starch  and  Paper-Starch  Dressing.— The  cotton-starch  dressing  of 
Burggraeve  and  the  paper-starch  dressing  of  Laugier  and  Heyfelder  are 
modifications  of  the  ordinary  simple  starch  dressing.  The  latter  is  made  by 
including  strips  of  paper  in  the  bandages  and  covering  them  with  starch 
paste.  In  the  cotton-starch  dressing  the  limb  is  enveloped  in  from  two  to 
four  rather  thick  layers  of  cotton  wool,  over  which  is  applied  the  starch- 
paste  dressing,  with  strips  of  pasteboard  softened  in  warra  water,  and  made 
to  fit  the  extremity  by  wrapping  over  them  a  mull  bandage  in  the  manner 
just  described. 

The  Water-Glass  Dressing  (Schrauth,  Schuh,  1857)  is  very  easily  put 
on,  is  cheap,  durable,  hard,  and  light,  and  is  also  impervious  to  water, 
but  has  the  disadvantage  of  requiring  twelve  to  twenty-four  hours  to 
harden.     It  is  best  to  use  a  freshly  made  solution  of  neutral  silicate  of 

potassium  having  a  specific  gravity  of 
from  1,35  to  1.40.  This  dressing,  like 
the  plaster  of  Paris,  is  applied  in  pre- 
pared bandages  which  have  been  satu- 
rated with  water  glass  having  the  con- 
sistence of  syrup.  About  five  to  six 
layers  of  the  water-glass  bandages  are 
sufficient.  It  is  best  to  use  a  flannel 
bandage,  or  cotton  and  a  mull  bandage, 
as  padding  to  lie  beneath  the  water- 
glass  bandages.  The  skin  should  be  care- 
fully protected  from  contact  with  the 
water  glass,  as  the  latter  is  liable  to  cause 
a  very  obstinate  eczema,  pai-ticularly 
when  old  solutions  are  used.  Further- 
more, the  water-glass  bandages  should 
not  be  carried  beyond  the  limits  of  the 
protective  padding,  as  the  sharp  edges 
of  the  splint  may  cut  into  the  skin.  The 
water-glass  splint  can  also  be  strengthened  by  including  in  it  thin 
strips  of  wood  or  other  material.     It  is  an  excellent  plan  to  mix  with 


Pig.  232.— Splints,  artificial  limbs,  and 
corsets,  made  of  water  glass. 


§  54.]    IMMOBILISATION  DRESSINGS  OF  HARDENING  SUBSTANCES.    225 

the  water  glass,  gypsum,  chalk,  cement,  etc.  These  substances  make 
the  dressing  harden  more  rapidly  and  render  it  very  firm  (Bohm, 
Konig,  the  author).  Bandages  are  soaked  in  the  thick  paste  and  ap- 
plied as  in  the  plaster  dressing,  or  the  jDaste  made  from  water-glass 
powder  is  applied  with  a  brush  to  the  bandages  after  they  have  been 
put  on.  At  the  end  the  entire  dressing  can  be  dusted  with  the  dry 
powder  and  painted  over  with  alcohol,  which  gives  it  a  hard,  glassy 
covering.  The  water-glass  splint  is  much  used  in  the  treatment  of 
inflamed  joints,  fractures,  etc.,  and  can  also  be  made  into  hinged,  re- 
movable splints.  Kappe'er  and  Hafter  have  shown  that  a  number  of 
apparatus,  artificial  limbs,  corsets,  articulated  splints,  etc.,  can  be  made 
of  water  glass*  (Fig.  232).  Fig.  232,  a  and  b,  represent  water-glass 
splints  for  the  lower  extremity,  provided  with  straps,  buckles,  strips  of 
caoutchouc,  and  fenestra  suitably  placed  for  permitting  movement  of 
the  joints  ;  c  is  a  contrivance  of  Taylor's  for  use  in  coxitis  (see  Regional 
Surgery) ;  d  represents  a  prothetic  apparatus  for  amputation  of  the 
arm ;  6  is  a  corset,  and  f  is  another  of  Taylor's  devices  for  kyphosis ; 
d  and  e  are  perforated  with  holes,  to  make  the  apparatus  light  and 
accessible  to  air. 

The  manufacture  of  immobilisation  appliances  from  moulded  felt 
and  gutta-percha  has  been  described  before  (see  pages  213,  214). 

Dextrine  Dressing. — Among  the  other  materials  which  have  not  found 
any  very  general  use  brief  mention  may  be  made  of  the  dextrine  dressing 
of  Velpeau  (1838).  It  is  applied  in  the  same  manner  as  the  starch  dressing, 
one  hundred  parts  of  dextrine  being  mixed  with  sixty  parts  of  spirits  of 
camphor  and  fifty  parts  of  water.  This  dressing  takes  from  four  to  seven 
hours  to  dry. 

Glue  Dressing. — The  glue  dressing  (A'^anzetti,  1846)  hardens  very  slowly. 
Strips  of  linen  or  roller  bandages  of  linen  or  muslin  are  spread  on  one  side 
with  joiner's  glue,  allowed  to  dry,  and  then  rolled  into  bandages  with  the 
glue  side  out.  The  bandages  immediately  before  use  are  dipped  in  hot  water 
and  applied  to  any  desired  region  over  a  protective  padding  bandage.  The 
same  procedure  can  be  adopted  as  in  starch  or  water-glass  dressings,  which 
consists  in  simply  saturating  bandages  and  splints  with  the  glue  after  they 
have  been  applied.  Thin  wooden  or  pasteboard  splints  can  be  incorporated 
in  the  dressing  to  strengthen  it. 

Magnesite  Dressing.— The  magnesite  dressing  is  most  excellent,  firm,  and 
durable.  Finely  powdered  magnesite  and  water  glass  are  mixed  into  a  thick 
paste.  The  method  of  applying  this  dressing,  wdiich  requires  some  twenty- 
four  to  thirty-six  hours  to  dry,  is  practically  the  same  as  for  the  starch  or 
water-glass  dressing — i.  e.,  either  the  magnesite  water-glass  paste  is  painted 
with  a  brush  over  the  dry  mull  bandages,  or  else  the  mull  or  cotton  bandages 

*  For  the  further  description  of  these  appliances,  see  Kappeler  and  Hafter,  Deutsch. 
Zeitschr.  fur  Chir.,  Bd.  vii.,  p.  129. 
16 


226  THE  APPLICATION  OF  IMMOBILISING  DRESSINGS. 

are  first  soaked  in  the  paste  and  tlien  applied  to  the  extremity  over  a  paddings 
of  flannel  bandaji'es. 

Cement  Dressing. — In  the  application  of  the  cement  dressing  a  mixture  of 
one  part  of  cement  to  two  to  three  parts  of  gypsum  is  employed,  and  this  is 
then  applied  like  the  gypsum  or  plaster-of-Paris  dressing. 

Other  Dressings. — The  gum  dressing  (Lorinser)  is  made  of  lime  or  cement 
dissolved  in  casein,  albumen,  gum  arable,  glue  and  other  materials  by  the 
addition  of  water. 

The  gum-chalk  dressing  of  Bryant  and  Wolfier  is  made  of  a  paste  of  gum 
arable  and  chalk  powder.  There  is  also  a  collodion  dressing,  a  resin  dress- 
ing, with  or  without  wax,  a  paraffine  and  stearine  dressing,  but  so  far  all 
these  have  not  come  into  general  use.  There  will  be  described  in  Regional 
Surgery  other  materials  which  are  used  in  the  preparation  of  jackets  for 
scoliosis  and  kyphosis,  but  which  may  also  be  used  for  splints  on  the  extremi- 
ties.    Heusner  uses  twisted  steel  wire  for  splint  purposes. 

§  55.  The  Method  of  employing  Extension  hy  a  Weight. — As  we  shall 
see  later  on,  permanent  extension  is  much  used — for  example,  in  chronic 
inflammations  of  joints  and  in  fractures.  The  method  of  applying  ex- 
tension by  a  weight  is  the  most  generally  used  of  all,  and  for  this  we 
have  to  thank  the  American  surgeons  Buck,  Crosby,  and  others,  as 
well  as  the  German  surgeons  Yolkmann  and  Bardenheuer.  The  pull- 
ing of  the  fragments  apart  by  a  weight  is  very  frequently  used  for  the 
lower  extremity  in  fracture  of  the  femur  and  for  diseases  of  the  hij) 
and  knee  joints,  and  consequently  we  must  describe  it  somewhat  at 
length. 

Extension  of  the  Lower  Extremity. — The  extension  dressing  for  a 
fracture  of  the  neck  of  the  femur  in  the  form  of  an  adhesive-plaster 
extension  contrivance  is  begun  m  the  case  of  adults  with  the  applica- 
tion of  a  strip  of  adhesive  plaster,  from  three  fingers  to  a  hand-breadth 
in  width,  along  the  inner  and  outer  side  of  the  leg,  in  such  a  way  that 
the  middle  of  the  strip  extends  in  the  form  of  a  loop  about  a  hand- 
breadth  beyond  the  sole  of  the  foot.  Before  applying  the  adhesive 
plaster  it  is  a  good  plan  to  shave  off  the  hairs,  to  prevent  the  latter  from 
sticking  to  the  plaster ;  then  strips  of  adhesive  plaster  (or  a  flannel 
bandage)  are  placed  circularly  around  the  leg  over  the  lateral  strips  at 
intervals,  or  overlapping  each  other,  beginning  just  above  the  malleoli 
and  going  to  the  head  of  the  fibula.  The  free  ends  of  the  adhesive 
plaster,  which  should  reach  to  the  middle  of  the  thigh,  are  then  split 
longitudinally  with  scissors  into  two  or  three  strips,  which  are  turned 
down  from  the  thigh  and  also  secured  about  the  leg  with  several  circu- 
lar strips  of  adhesive  plaster.*     In  this  manner  the  lateral  strips  of 

*  In  this  country  the  strips  are  not  turned  down,  but  left  applied  to  at  least  half 
the  length  of  the  thigh  above  the  knee,  to  lessen  the  traction  on  the  ligaments  of  the 
knee-joint. — [Trans.] 


§55.]     THE  METHOD  OF  EMPLOYING  EXTENSION  BY  A  WEIGHT.    227 

adhesive  plaster  are  secured  to  the  leg  very  firmly.  I  avoid  placing 
strips  circularly  around  the  leg  in  the  region  of  the  head  of  the  fibula, 
as  this  practice  sometimes  has  been  known  to  cause  a  pressure 
paralysis  of  the  external  popliteal  nerve.  In  the  loop  made 
by  the  adhesive  plaster  below  the  foot  a  small  piece  of 
board  is  fastened  in  place  to  prevent  chafing  of  the  skin  over 
the  malleoli.  Through 
a  hole  in  the  centre  of 
this  board  is  passed  the 
rope  to  which  the  ex- 
tension weight  is  at- 
tached. The  rope  is 
fastened  to  the  board 
by  knotting  it  on  the 
side  next  the  foot,  or 
it  may  simply  be  at- 
tached by  a  hook  (Figs.  233,  235).  The  rope  to  which  the  weight  is 
fastened  for  making  the  extension  runs  over  two  rollers  fastened  to  the 
patient's  bed  (Fig.  233).  This  dressing  can  be  made  more  firm  and 
durable  by  applying  over  it  a  layer  of  mull  bandage,  and  over  this  a 
gauze  bandage,  or,  better  still,  a  water-glass  or  chalk-water-glass  dress- 
ing. To  lessen  the  amount  of  the  chafing  to  which  the  limb  is  sub- 
jected, and  to  regulate  the  position  of  the  foot,  it  is  a  good  plan  to  use 


Fig.  233. — Extension  apparatus. 


Fig.  234— Extension  with  suspension  by  means  of  a  gypsum-hemp  splint  or  a  telegraph-wire 
splint  for  fractures  of  the  femur. 


Yolkmann's  sliding  foot  rest  (Fig.  233),  which  consists  of  a  tin  gutter 
splint  for  the  leg,  padded  with  cotton  or  jute,  and  having  a  removable 
foot-piece  attached  to  a  wooden  cross-bar.  The  cross-bar  slides  on 
two  longitudinal  strips  of  wood.     Other  sliding  foot  rests  have  been 


228 


THE   APPLICATION   OF   IMMOBILISING  DRESSINGS. 


iuvented  bj  Riedel  and  Wahl.     If  Yolkmann's  contrivance  is  em- 
ployed, any  hardening  dressing,  such  as  the  water-glass  bandage,  must 


Fig.  235. — Vertical  suspen.sioa  with  a  plaster  dressing,  the  knee  being  bent  at  a  right  angle. 


of  course  be  applied  so  as  to  include  the  leg  sphnt.     The  weight  of  the 

body  is  ordinarily  employed  for  making  counter  extension,  the  patient 

being  kept,  if  possible,  in  the  horizontal  position  while  the  foot  of  the 

bed  is  raised  by  a  couple  of  blocks  of  wood  ;  or  a 

pelvic  or  perineal  girdle,  made,  for  example,  from  a 

rubber  bandage,  can  be  carried  ai-ound  the  patient's 

perineum,  thence  to  the  head  of  the  bed,  and  attached 

to  a  weight  by  a  cord  running  over  a  couple  of  rollers. 

As  adhesive  plaster  is  sometimes  uncomfortable, 

and  may  cause  a  troublesome  eczema,   emplastrum 

cerussae  may  be  used  in  its  j^lace ;  or  perhaps  a  better 

plan  is  to  enclose  the 
limb  in  a  flannel  band- 
age, and  to  attach  to 
this  extension  strips 
made  of  pieces  of  linen 
cloth ;  or  a  strong  and 
not  too  elastic  raljber 
bandage  may  be  sewed 
laterally  to  the  turns 
of  the  flannel  bandage. 
Personally  I  find  the 
following  method  of  applying  the  extension  apparatus  much  simpler 
than  the  one  just  given.     Two  long  strips  of  sole  felt,  or  piano  felt, 


Fig.  236.- 


-Vertical  suspension  for  fractures  of  the  femur  in 
childi-en. 


§55.]     THE  METHOD  OF  EMPLOYING  EXTENSION  BY  A  WEIGHT.    229 

or  buck-skin  are  cut  to  correspond  to  the  length  of  the  limb  and  from 
6  to  10  centimetres  in  width.  The  two  lower  ends  are  joined  together 
by  a  strip  of  canvas.  The  two  strips  of  felt  are  secured  by  an  adhe- 
sive material,  which  is  applied  to  the  sides  of  the 
leg,  and  by  circular  turns  of  a  bandage.  The  con- 
stituents of  the  adhesive  material  are  as  follows : 
Cer?e  flavse,  resin,  damarak,  colophon,  aa  10.0 ; 
terebinth.  1.0 ;  ether,  alcohol,  oleum  terebinth. 
aa  55.0,  This  mixture  is  filtered.  In  from  two 
to  three  hours  the  felt  or  buck-skin  strips  are 
firmly  adherent  to  the  leg,  and  the  extension  can 
then  be  begun  in  the  way  described  above.  Ex- 
tension may  also  be  combined  with  some  one  of 
the  various  kinds  of  immobilising  dressings,  such 
as  plaster  of  Paris.  Recently  the  cord  for  exerting 
the  traction  has  been  attached  by  means  of  hooks 
and  cross-bars  to  rubber  tubing  filled  with  air  ap- 
plied around  the  region  just  above  the  malleoli. 

In  the  after-treatment  of  cases,  such  as  a  hip- 
joint  resection,  where  extension  is  only  required 
at  night,  gaiters  are  applied  reaching  to  the  middle  of  the  thigh  and 
having  a  leather  foot-piece  to  which  is  fastened  the  cord  for  exerting 
the  traction. 

If  it  is  desired  to  apply  ex- 
tension to  the  thigh  in  a  some- 
what abducted  position,  as  after 
resection  of  the  head  of  the 
femur,  rollers  can  be  attached 
to  a  board,  which  may  be  fas- 
tened with  screws  to  any  de- 


FiG.  237. — Extension  at 
the  shoulder  by  a 
weight. 


Fig.  238.— Extension  on  the  upper  arm :  a,  gutter  splint ;  b,  splint  with  weight  extension. 


sired  part  of  the  bed,  while  the  cord  for  exerting  the  traction  is  carried 
over  a  wooden  frame  placed  near  the  bed. 


230 


THE  APPLICATION  OF   IMMOBILISING  DRESSINGS. 


Frequentlj,  in  cases  of  fracture  of  the  lower  extremity,  extension  is 
combined  with  suspension,  as  iUustrated  in  Figs.  23-i,  235,  and  236.  It 
i-equires  no  further  explanation. 

Extension  of  the  Upper  Extremity  is  carried  out  by  means  of  adhesive 
plaster  applied  to  the  shoulder-joint  and  arm,  according  to  the  methods 

of  Bardenheuer  and  Hamilton, 
or  of  Lossen  or  Hofmokl.  Ex- 
tension upon  the  upper  extrem- 
ity has  by  no  means  the  im- 
portance that  it  has  upon  the 
lower.  Hamilton's  extension  at 
the  shoulder-joint  (Fig.  237)  is 
applied  by  means  of  adhesive 
plaster  and  a  weight,  while  coun- 
ter extension  is  made  with  a 
crutch  in  the  axilla,  the  crutch 
being  supported  by  a  belt  around 
the  waist.  Lossen' s  extension  for 
the  arm  (Fig.  238)  is  applied  by 
laying  the  arm  on  a  splint  which 
is  fastened  to  the  patient's  bed. 
The  way  in  which  the  traction 
is  exerted  by  adhesive  -  plaster 
strips  is  represented  in  the  figure 
and  needs  no  further  description. 
Hofmokl  has  also  devised  an  ex- 
cellent apparatus  for  applying  extension  by  a  weight  to  the  upper 
extremity  (Fig.  239).  There  is  seldom  any  need  of  applying  extension 
at  the  elbow-joint,  but  for  the  forearm  and  wrist-joint  Langenbeck's 


Fig.  239. — Extension  by  a  weight  applied  to  the 
upper  extremity  (Hofmokl).  In  extension  by 
weight  of  the  upper  arm  tlie  looj^s  1  and  3  are 
not  used  ;  in  case  of  the  forearm  2  is  not  used  ; 
the  extension  is  then  made  at  3  and  counter 
extension  at  1. 


Fig.  240. — Extension  of  the  forearm  and  hand. 


method  (Fig.  240)  can  be  used.  Extension  by  a  weight  can  also  be 
employed  for  the  metacarpus  and  fingers  by  means  of  loops  of  adhesive 
plaster.     Extension  by  suspending  the  arm  is  illustrated  in  Fig.  194. 


§55.]    THE  METHOD  OF  EMPLOYING  EXTENSION  BY  A  WEIGHT.     231 


Extension  of  the  Spine. — The  following  is  a  brief  description  of  the 
methods  of  using  extension  for  the  vertebrae :  For  fractures  and  tuber- 
cular inflammation  of  the  vertebrae,  Glisson's  leather  sling  with  a  metal 


T'iG.  241. — Permanent  extension  by  weight  by  means  of  Glisson's  sling  for  cases  of  spondylitis. 

arch  (Fig.  241)  is  employed,  or  Falkson's  chin-neck  sling  of  emplastrum 
cerussse  (Fig.  212).  E.  Fischer's  suggestion  is  excellent :  A  four-cor- 
nered piece  of  cloth  is  provided  with  openings  for  the  face  and  neck ; 
it  is  then  padded  in  the  region  of  the  chin  and  back  of  the  neck,  and 
the  four  corners  of  the  cloth  ai*e  brought  together  over  the  top  of  the 


T'iG.  242.— Falkson's 
sling  for  the  chin 
and  back  of  the 
neck,  made  of  ce- 
russa  plaster  and 
used  for  extension 
of  the  vertebral 
column. 


Fig.  243. — Fixation  and  extension  of  the  cervical  vertebrae  for  spondy- 
litis cerviealis  and  dorsalis  by  means  of  the  jury-mast. 


Lead  and  connected  with  the  cord  used  for  exerting  the  traction. 
Counter  extension  is  furnished  by  the  weight  of  the  body — i.  e.,  the 
iead  of  the  bed  is  raised,  or  extension  is  applied  to  the  legs. 


232 


THE   APPLICATION   OF   IMMOBILISING  DRESSINGS. 


Ill  cases  of  tubercular  inllammatiou,  for  example,  of  the  cervical 
vertebrae,  the  latter  may  be  fixed  and  extended  by  means  of  the  jury- 
mast  corset  (Sayre,  Figs.  243,  244).  For  extension 
of  the  lumbar  and  dorsal  vertebrae  it  is  best  to  use 
tlie  weight  of  the  patient's  body  by  placing  him 
either  in  a  Rauchfuss  hammock  (Fig.  245)  or  in  a 
Barwell's  sling.  The  methods  of  applying  these  dif- 
ferent dressings  will  be  described  in  the  Regional 
Surgery. 

The  Amount  of  Force  to  be  used  in  Extension. — 
The  amount  of  traction  which  may  be  employed  in 
the  different  extension  appliances  varies  with  the  age 
of  the  patient  and  the  nature  of  the  disease  or 
injur3\  For  fractures  of  the  femur  and  hip-joint 
inflammations  in  small  children,  one  to  two  to  three 
kilogrammes  are  used ;  for  children  from  ten  to 
twel  ve  years  old,  somewhat  more ;  while  in  adults 
ten  to  fifteen  kilogrammes  may  be  needed. 

Extension   by   Splints. — Extension    by   splints   is 

much  less  used  now  than   was  formei'ly  the  case. 

Reference  will  be  made  in  the  text-book  on  Regional  Surgery  to  the 

splints  used  for  extension  purposes,  especially  under  the  treatment  of 

injuries  and  diseases  of  the  hip  and  lower  extremities.    Numerous  por- 


FiG.  244.— Felt  corset 
with  jury-mast  for 
lixatioii  of  the  head 
in  spondylitis  cer- 
vicftlis. 


Fig.  245. — Position  of  the  patient  in  Eauchfuss's  hammock  in  cases  of  tiihercular  spondylitis. 


tative  extension  splints  have  been  devised  of  late  (see  Regional  Sur- 
gery, Injuries  and  Diseases  of  the  Lower  Extremities).  For  a  descrip- 
tion of  portative  splints,  see  The  Treatment  of  Fractures. 


THIRD    SECTION. 
SURGICAL  PATHOLOGY  AND  THERAPY. 


CHAPTER  I. 

INFLAMMATION   AND    INJTJKIES. 

The  phenomena  of  inflammation. — The  histological  changes  which  take  place  in  in- 
flammation.— Causes  of  inflammation. — Symptoms  of  inflammation. — Termina- 
tions.— Diagnosis. — Treatment. — Morphology  and  significance  of  micro-organisms 
(microbes). — Injuries  in  general. — The  histological  changes  which  occur  in  the 
healing  of  a  wound. — The  reaction  following  wounds  and  inflammations. — Fever. — 
Shock. — Delirium  tremens. — Delirium  nervosum. — Disturbances  which  may  arise 
during  the  healing  of  a  wound. — Infection  of  wounds. — Inflammation. — Suppura- 
tion of  the  wound. — Lymphangitis. — Arteritis. — Phlebitis. — Cellulitis. — Erysipe- 
las.— Wound  diphtheria  (hospital  gangrene). — Tetanus. — Septicaemia. — Pyaemia. — 
Infection  by  cadaveric  poison. — Other  kinds  of  infection. — (Anthrax  ;  symptomatic 
anthrax. — Glanders. — Hoof  and  mouth  disease. — Hydrophobia.) — Poisoning  by  in- 
sects, snakes,  etc. — Curare  poisoning. — Appendix:  Chronic  microbic  diseases. — 
Tuberculosis. — Syphilis. — Leprosy. — Actinomycosis. 

§  56.  Inflammation. — The  physicians  of  antiquity  recognised  the 
four  cardinal  symptoms  of  inflammation  :  Redness  (rubor),  heat  (calor), 
swelling  (tumour),  and  pain  (dolor).  But  these  outward  manifestations 
do  not  throw  light  upon  the  source  and  essence  of  inflammation.  The 
question,  where  the  origin  of  the  process  is  to  be  found,  has  always 
been  a  subject  of  discussion,  and  the  principal  part  in  the  production 
of  inflammation  has  been  ascribed  in  turn  to  the  blood,  to  the  tissues, 
to  the  blood-vessels,  and  to  the  nerves.  ISTumberless  experiments  have 
been  performed  and  the  most  diverse  theories  have  been  advanced  to 
account  for  the  phenomena  of  inflammation.  Yirchow  founded  the 
cellular -pathology  theory,  according  to  which  an  "inflammatory  irrita- 
tion "  leads  to  deflnite  changes  in  the  cells.  Cohnheim  ascribed  it  to  a 
probable  molecular  change  in  the  walls  of  the  vessels,  while  Reck- 
linghausen and  Thoma  laid  stress  upon  the  vasomotor  nerves,  and  par- 
ticularly upon  their  centres  located  in  the  inflamed  region.  Of  the 
various  inflammatory  irritants  or  causes  of  inflammation,  micro-organ- 

233 


234 


INFLAMMATION  AND  INJURIES. 


isms  and  the  products  of  their  metabolism  should  be  looked  upon  as 
the  most  important. 

Changes  in  the  Circulation  in  an  Inflamed  District. — In  order  to 
understand  the  nature  of  intlannnation,  it  is  best  tirst  to  study  what 
takes  place  in  the  circulatory  system.  Cohuheim  has  shown  how  these 
processes  may  be  watched  under  the  microscope.  The  intestine  of  an 
etherised  or  eurarised  frog  is  drawn  out  through  an  opening  made  in 
the  side  of  the  abdominal  wall,  and  the  mesentery  is  spread  out  on  a 
slide  beneath  a  microscope.  In  this  way  the  mesentery,  with  its  ves- 
sels, is  subjected  to  the  influence  of  the  air  and  the  irritating  substances 
in  it,  particularly  the  micro-organisms.  After  a  short  interval  an 
inflammation  begins,  all  the  various  manifestations  of  which  can  be 
observed  from  beginning  to  end,  and  all  the  more  exactly  if  the  prepa- 
ration is  protected  from  all  bruising,  drying,  or  soiling,  etc.  The 
webbing  between  the  toes  or  the  tongue  of  the  frog  can  be  used  in 
the  same  manner  ;  the  tongue  is  drawn  out  and  fastened  with  insect 

pins  to  a  cork  rim  ai'ound  a 
slide,  and  then  by  cauteris- 
ing or  scratching  the  papillae 
an  inflammation  can  be  pro- 
duced and  the  various  phe- 
nomena studied. 

There  is  tirst  seen  a  dila- 
tation of  the  exposed  vessels 
of  the  mesentery,  if  that  is 
employed,  beginning  in  the 
arteries  and  extending  to  the 
veins,  and  to  a  less  extent 
involving  the  capillaries.  Si- 
multaneously with  the  dila- 
tation of  the  vessels  the  blood 
stream  begins  to  flow  more 
rapidly,  and  this  is  followed 
sooner  or  later,  in  from  half 
an  hour  to  an  hour,  by  a 
marked  slowing  of  the  cur- 
rent. As  a  result  of  this  slowing  the  separate  corpuscles  can  be  distin- 
guished in  the  veins  and  capillaries,  and  even  in  the  arteries ;  and  they 
will  be  found  to  accumulate,  especially  in  the  veins  and  capillaries.  In 
the  veins,  particularly,  there  will  be  large  numbers  of  colourless  blood- 
corpuscles  in  the  peripheral  portion  of  the  current,  and  occasionally 
they  will  stick  to  the  inner  walls  of  the  veins  (peripheral  stasis  of  the 


Fig.  246. — Inflamed  me*entery  of  a  frog :  V.  vein  • 
A,  small  artery  and  capillaries.  The  vessels  con- 
tain white  blood-corpuscles  on  their  inner  walls, 
some  being  in  the  process  of  emigration;  the" 
surrounding  tissues  contain  numerous  leucocytes 
which  have  already  emigrated  from  the  vessels. 


56.] 


INFLAMMATION. 


235 


Fig.  247. — Emigration  of  leucocytes  :  a,  Incomplete,  b,  com- 
plete emigration  (schematic). 


white  corpuscles  or  leucocytes,  Fig.  24.6).  The  red  cells,  on  the  con- 
trary, continue  to  flow  along  with  diminished  rapidity  in  the  centre  of 
the  stream.  Presently,  following  the  peripheral  stasis  of  the  white 
cells,  there  will  be  observed  a  new  phenomenon  :  a  point  ^vill  be  seen 
to  project  from  the  ex- 
ternal contour  of  some 
vein  or  capillary,  and 
then  gradually  become 
larger  and  more  and 
more  prominent  (Fig. 
24:7,  a)  ;  and  finally  this 
bit  of  protoplasm  will 
only  remain  attached  to 
the  wall  of  the  vessel  by 
one  or  more  processes, 
and  at  last  becomes  en- 
tirely separated,  which 
means  that  a  white  cor- 
puscle has  made  its  way 
out  of  the  vein  or  capillary  (Fig.  247,  b).  Six  or  eight  hours  later  this 
process  has  continued  to  such  an  extent  that  the  veins  and  capillaries 
are  surrounded  by  these  migrated  white  cells.  In  addition  to  these 
cells,  which  are  usually  polynuclear,  there  will  be  found  small  round 
mononuclear  cells  (lymphocytes),  which,  according  to  Grawitz  and  Eib- 
bert,  are  to  be  regarded  as  derived  from  the  fixed  connective  tissue 
cells,  though  Baumgarten  claims  that  they  are  likewise  white  corpuscles 
which  have  migrated  from  the  vessels  of  the  same  region  (leucocytes). 
According  to  Baumgarten,  the  small  mononucleated  lymphocyte  form 
of  leucocyte  is_  the  predominant  element  in  chronic  inflanmiations. 
Waller  was  the  first  (1846)  to  note  the  migration  of  the  leucocytes 
from  the  interior  of  the  vessels,  but  his  observations  had  been  entirely 
forgotten  when  Cohnheim  rediscovered  this  phenomenon  in  186 7. 

Eed  blood  disks  also  pass  through  the  walls  of  the  capillaries,  but 
not  of  the  veins,  for  in  the  capillaries  both  classes  of  cells  come  in  con- 
tact with  the  walls,  and  are  not,  as  in  the  veins,  confined  to  separate 
parts  of  the  blood  current.  The  proportion  of  red  cells  contained  in 
the  exudate  varies  ;  some  lie  here  and  there  on  the  outer  wall  of  the 
-capillaries,  some  collect  in  tiny  punctate  hsemorrhages,  and  some  are 
washed  away  in  the  stream  of  transuded  serum.  ISTo  blood-corpuscles 
migrate  through  the  walls  of  the  arteries. 

The  time  required  for  a  white  cell  to  pass  through  the  wall  of  a 
capillary  or  vein  varies,  and  the  same  holds  true  as  to  the  passage 


236  INFLAMMATION  AND  INJURIES. 

(diai3edesis)  of  a  red  cell  through  the  wall  of  a  capillar3\  Sometimes 
the  movement  is  slow,  while  at  others  a  few  minutes  are  enough  for 
three,  four,  or  more  cells  to  escape  one  after  the  other  at  the  same 
spot ;  and  immediately  thereafter  the  blood  stream,  with  its  corpuscles, 
flows  on  normally  past  the  point  where  they  have  escaped. 

Significance  of  the  Escape  of  the  Leucocytes. — As  Leber  has  demon- 
strated, the  escape  of  the  leucocytes  from  the  vessels  is  not  unregu- 
lated, but  they  obey  an  attraction  towards  the  place  of  irritation  simi- 
lar to  that  observed  by  Pfeffer,  O.  Hertwig  and  Engelmanu  in  vegetable 
cells  and  bacteria  upon  which  certain  chemical  substances  exert  a 
peculiar  power  of  attraction  (chemotaxis).  The  substances  which  act 
in  this  manner  on  bacteria  are  the  salts  of  potassium,  peptones,  and 
especially  all  nutritive  substances ;  while  other  substances,  such  as  free 
acids  and  alkalies  or  alcohol,  have  a  repellent  jjower  (negative  chemo- 
taxis). These  facts,  which  Pfeffer  has  demonstrated  experimentally 
for  the  fungi,  have  a  most  important  bearing  upon  the  subject  of  in- 
flammation. This  power  to  attract,  or  chemotaxis,  influences  or  even 
controls  the  movements  of  the  leucocytes  in  the  tissues  towards  the 
focus  of  inflammation,  also  the  actual  migration  of  the  cells  from  the 
vessels  and  later  the  formation  of  new  vessels  at  the  same  point.  The 
leucocytes  are  especially  attracted  by  the  bacteria  and  the  products  of 
their  metabolism,  as  well  as  by  different  chemical  substances,  such  as 
copper,  mercury,  croton  oil,  turpentine  oil,  etc.  According  to  Bloch, 
they  are  attracted  chiefly  by  the  easily  assimilated  albuminous  bodies 
and  carbohydrates  which  are  closely  allied  to  the  animal  tissues.  Ac- 
cording to  Buchner,  the  protoplasm  of  bacterial  cells  contains  substances 
which  exert  this  attraction  upon  the  leucocytes,  the  so-called  bacterial 
proteins  which  ISTencki  studied  as  early  as  1880  in  certain  kinds  of 
bacteria,  from  a  purely  chemical  standpoint.  These  proteins  will  pro- 
duce inflammation  or  suppuration  only  after  they  have  become  sepa- 
rated from  the  bacterial  cell,  consequently  only  after  the  latter  has  died 
or  become  diseased.  Borissow  found  that  chemotaxis  was  much  more 
active  in  young  animals  than  in  full-grown  ones.  He  could  not  deter- 
mine that  a  particular  substance  attracted  a  special  vai-iety  of  leucocyte. 
The  assembling  of  cells  at  the  seat  of  inflammation  is  to  be  regarded 
as  essentially  a  protective  measure  taken  by  the  organism  for  the  pur- 
pose of  defending  itself  against  external  noxious  influences.  The  leu- 
cocytes serve,  perhaps,  to  eliminate,  to  liquefy,  and  to  separate  the 
inflammatory  focus  from  the  healthy  living  tissues  (Leber). 

Increased  Exudation. — Accompanying  the  migration  or  extravasa- 
tion of  blood-cells  there  is  an  increased  transudation  of  the  liquid 
elements  which  infiltrate  all  the  surrounding  tissues.     This  increases 


§  56.]  INFLAMMATION.  237 

the  amount  of  the  lymph  current  until  the  lymph  channels  become 
inadequate  for  carrying  away  the  transuded  liquid,  and  then  results  a 
sweUing  of  the  part  of  the  body  which  is  inflamed.  Partly  as  a  result 
of  their  own  power  of  locomotion,  and  partly  carried  along  by  the 
transuded  fluid,  the  white  blood-corpuscles  become  distributed  through 
the  tissues  at  ever-increasing  distances  from  the  vessels  out  of  which 
they  have  wandered.  Finally,  both  the  corpuscles  and  the  exudate 
make  their  way  to  the  surface  of  the  mesentery,  and  there  the  exudate 
coagulates,  forming  a  so-called  false  membrane,  which  is  filled  with 
numberless  white  blood-corpuscles  and  a  few  red  ones. 

Corresponding  to  the  great  number  of  leucocytes  which  it  contains, 
the  inflammatory  exudate  is  very  rich  in  albumen,  while  the  exudate 
which  follows  passive  congestion  is  not  (Hoppe-Seyler,  Lassar).  Only 
in  cases  of  mild  inflammation,  or  in  the  early  stages  of  others,  does  the 
exudate  contain  a  small  number  of  cells. 

According  to  the  character  of  the  inflammatory  exudate,  we  dis- 
tinguish it  as  serous,  fibrinous,  croupous,  diphtheritic,  suppurative, 
hsemorrhagic,  and  ichorous. 

Proliferation  of  Connective-tissue  Cells  in  Inflammation. — Xot  all 
of  the  cells  which  are  found  in  inflamed  parts  are  migrated  leuco- 
cytes. The  flxed  connective-tissue  cells  proliferate  by  rapid  division, 
and  contribute  notably  to  the  cellular  inflltration  of  the  inflamma- 
tory focus. 

According  to  Strieker  and  Grawitz,  the  intercellular  substance  of 
the  tissues  undergoes  a  cellular  metamorphosis  when  inflamed,  revert- 
ing to  its  embryonic  cellular  state.  The  cells  also  which  have  hitherto 
lain  dormant  in  the  stroma  (dormant  cells,  Grawitz)  are  said  to  awake 
to  renewed  activity.  The  views  which  Grawitz  has  expressed  con- 
cerning the  process  of  inflammation  are  of  great  scientiflc  interest,  but 
they  greatly  lack  the  support  of  observed  facts,  and  have  not  yet  met 
with  general  acceptance. 

Inflammation  from  Croton  Oil. — The  manifestations  of  inflammation  just 
described  can  also  be  produced  by  irritating  the  frog-'s  tongue  with  very 
dilute  croton  oil  fl..50  of  olive  oil),  by  cauterising  it  with  a  stick  of  nitrate  of 
silver,  or  by  applying  a  ligature  to  temporarily  shut  off  the  blood  from  the 
vessels  of  the  tongue.  Precisely  similar  phenomena  can  be  observed  in 
warm-blooded  animals— for  instance,  in  the  mesentery  of  a  small  rabbit. 
All  the  gross  changes  which  take  place  in  an  inflammation  can  be  produced 
in  a  rabbit's  ear  by  painting  it  with  croton  oil,  cauterising  it,  applying  a 
ligature,  or  by  subjecting  it  to  heat  or  cold,  as  by  dipping  it  in  hot  water  or 
lightly  freezing  it  with  a  cooling  mixture.  An  ear  which  has  been  subjected 
for  even  a  few  minutes  to  a  temperature  of  .56°  to  60°  C.  (140°  to  147°  F.).  or 
—18°  to  —20°  C.  (—1°  to  —4°  F.),   will  inevitably  necrose.     After  a   rabbit's 


238  ■   INFLAMMATION  AND  INJURIES. 

ear  lias  recovered  from  the  effects  of  crotoii  oil,  it  gains,  according  to  Samuel, 
a  kind  of  imiliunity  as  regards  this  drug — i.  e.,  it  reacts  to  a  subsequent 
application  of  the  oil  much  less  violent!}-  than  an  ear  which  has  not  been  so 
treated. 

The  phenomena  thus  described — viz.,  the  simple  congestive  hyper- 
Eemia,  the  extravasation  of  the  corpuscular  elements  from  the  capilla- 
ries and  veins,  the  increased  exudation  terminating  in  stasis  and  later 
in  death  of  tissue,  and  also  the  proliferation  of  the  tixed  connective- 
tissue  cells — form  a  group  of  symptoms  which  we  are  accustomed  to 
designate  by  the  name  of  inflammation. 

Cause  of  Inflammation. — Cohnheim  ascribed  the  cause  of  all  these 
phenomena  and  the  essence  of  inflammation  to  molecular  changes  in 
the  walls  of  the  vessels.  According  to  him,  these  molecular  changes 
increase  the  adhesiveness,  and  consequently  the  friction,  between  the 
blood  and  the  walls  ;  hence  the  slowing  of  the  stream.  Exactly  what 
kind  of  a  change  is  produced  in  the  vessel  walls  in  inflammation  is  not 
clearly  understood ;  it  cannot  be  detected  with  the  microscope,  and  we 
can  only  say  that  the  walls  become  more  pervious,  enough  so  to  occa- 
sion the  increase  in  exudation  notwithstanding  the  diminution  of  the 
blood  pressure  which  takes  place  especially  in  the  capillaries.  Wini- 
warter has  shown  that  a  colloid  liquid,  such  as  a  solution  of  glue,  can 
pass  through  the  inflamed  walls  of  blood-vessels  even  when  the  pres- 
sure is  subnormal.  A  rupture,  an  interruption  of  continuity  in  the  wall 
of  the  vessel,  permitting  the  escape  of  the  leucocytes  and  of  a  few  red 
corpuscles,  certainly  does  not  take  place.  Likewise,  Arnold's  theory 
that  in  inflammation  the  natural  stomata  between  the  endothelial  cells 
become  enlarged  and  that  new  ones  form,  is,  as  Cohnheim  always  main- 
tained, incorrect.  Cohnheim's  comparison  of  inflammatory  exudation 
with  filtration  seems  very  appropriate.  Under  normal  conditions  only 
a  small  amount  of  a  thin  liquid  can  pass  through  the  filter  of  the  vessel 
wall ;  but  when  inflammation  sets  in  the  filter  becomes  coarser  and 
permits  not  only  denser  solutions  to  pass  through,  but  also  formed  ele- 
ments, the  blood -corpuscles.  The  change  produced  in  the  vessel  wall 
by  inflammation  is,  according  to  Cohnheim,  probably  chemical. 

But  all  the  manifestations  of  inflammation  cannot  be  explained  by 
the  condition  of  the  vessel  walls,  which  Cohnheim  thought  was  sufii- 
cient.  The  investigations  recently  made  by  Recklinghausen,  Arnold, 
and  others  go  to  show  that  Cohnheim's  theory  needs  certain  limitations 
in  view  of  the  fact  that  a  distinction  must  be  made  between  the  exuda- 
tion of  fluid  constituents  of  the  blood  and  the  emigration  of  white  cor- 
puscles. Thoma's  researches  have  shown  that  a  primary  alteration  in 
the  walls  of  the  vessels  is  not  always  the  cause  of  the  emigration,     A 


§  56.]  INFLAMMATION.  239 

simple  disturbance  of  circulation  following  an  irritation  of  the  local 
vasomotor  centres  pi'oduces  a  peripheral  stasis  and  an  eruigration  of 
leucocytes.  But  the  latter  phenomenon  will  only  last  a  brief  time  in 
those  cases  in  which  there  is  no  other  influence  at  work ;  the  vasomotor 
nerves  resume  their  function,  and  the  peripheral  slowing  of  the  cur- 
rent and  the  escape  of  the  leucocytes  cease.  If  the  disturbances  in 
innervation  are  more  marked,  and  if  the  emigration  is  allowed  to  go  on 
for  a  longer  time,  a  secondary  change  in  the  walls  of  the  vessels  takes 
place.  But  in  these  cases  the  disturbance  in  the  innervation  of  the 
vessels  is  the  primary  event,  and  not  the  alteration  in  their  walls. 
Thus  Recklinghausen  seems  to  be  correct  in  ascribing  to  the  vaso- 
motor nerves,  and  particularly  to  their  terminal  local  centres,  an  im- 
portant part  in  the  inflammatory  process,  and  especially  in  the  emigra- 
tion of  the  leucocytes.  Herpes  zoster  and  other  diseases  resulting 
from  disturbances  in  innervation  go  to  prove  the  truth  of  this  theory. 
Samuel  has  shown  that  the  inflammatory  process  becomes  more  severe 
when  there  is  vasomotor  paralysis.  Moreover,  the  emigration  of  leu- 
cocytes is  afi^ected  in  both  a  positive  and  negative  way  by  the  above- 
mentioned  chemotaxis.  On  the  other  hand,  the  exudation  of  the  fluid 
elements  of  the  blood  during  an  inflammation  can  only  be  explained 
by  a  change  in  the  permeability  of  the  walls  of  the  vessels,  located  in 
either  the  endothelial  cells  or  the  cement  substance  between  them. 

According,  then,  to  our  present  knowledge,  we  must  look  for  an 
explanation  of  the  phenomena  of  inflammation  (1)  in  vasomotor  changes 
in  the  vessels,  or,  rather,  in  disturbances  within  the  vasomotor  centres  in 
the  walls  of  the  vessels ;  (2)  in  an  increased  permeability  of  these  walls  ; 
(3)  in  the  positive  (attracting)  and  negative  (repelling)  chemotaxis  of 
the  inflammatory  focus,  and  flnally  (4)  in  the  reactionary  proliferation 
of  the  cells  in  the  inflamed  tissues.  It  is  an  exceedingly  diflicult  mat- 
ter to  give  an  exhaustive  and  satisfactory  definition  of  inflammation. 

Other  Theories  of  Inflammation. — Before  Cohnheim,  Recklinghaxisen,  and 
Thoma  had  established  the  above  explanation  of  iuflammation,  a  great  va- 
riety of  theories  had  been  advanced,  the  most  important  being  the  neuro- 
humoral fCullen,  Henle)  and  the  cellular  (A^irchow).  According  to  the  for- 
mer, the  nature  of  inflammation  or  the  disturbances  in  the  circulation  are 
explained  either  by  the  contraction  or  dilatation  of  the  afferent  arteries,  pro- 
duced reflexly  through  stimulation  of  the  sensory  nerves.  We  have  seen 
that  nervous  influences  really  do  play  an  active  part  in  the  process  of  inflam- 
mation. 

Virchow's  cellular  theory  of  inflammation  is  based  upon  the  changes  in 
the  life  of  the  cells  brought  about  by  the  primary  causes  of  inflammation. 
Virchow  regarded  the  cells  of  the  tissues  as  the  essential  elements  in  the 
inflammatory  process.     As  a  result  of  the  inflammatory  irritation  they  were 


240  INFLAMMATION   AND   INJURIES. 

caused  to  swell  and  proliferate  and  form  pus-corpuscles.  These  altered  cells 
are  supposed  by  Vircliow  to  exercise  a  kind  of  attractive  power  for  the  con- 
tents of  the  vessels,  producing:  increased  exudation. 

Samuel  thinks  that  inflammation  is  due  to  a  changed  relationship  of  the 
blood,  the  walls  of  the  vessels,  and  the  tissues  to  each  other.  Recklinghau- 
sen agrees  with  him  in  general. 

Landerer  thinks  that  the  inflammatory  changes  in  the  circulation  depend 
upon  a  disturbance  of  the  normal  balance  between  the  blood  pressure  and 
the  tension  of  the  tissues,  caused  by  a  change  in  the  elastic  properties  of  the 
ti-ssues  and  the  walls  of  the  vessels.  This  change  in  elasticity,  he  is  inclined 
to  believe,  is  the  primary  factor,  though  he  admits  that  the  walls  of  the  ves- 
sels may  become  primarily  diseased. 

No  one  of  these  theories  can  by  itself  explain  the  nature  of  inflammation, 
especially  if  that  theory  is  based  upon  only  a  single  manifestation  of  the  in- 
flammatory jjrocess  and  attemjits  to  solve  the  problem  from  this  standpoint 
alone.  Consequently,  it  is  evident  why  Cohnheim's  attempt  to  explain  in- 
flammation by  a  change  in  the  walls  of  the  vessels  is  to-day  regarded  as 
inadequate.  No  value  can  be  attached  to  any  theory  which  does  not  include 
a  correct  exjilanation  of  the  changes  produced  under  the  stimulus  of  inflam- 
mation in  both  the  solid  and  fluid  elements  of  the  tissues  (cells,  nerves,  and 
walls  of  the  vessels),  and  does  not  consider  these  in  their  causal  relationshii^ 
to  one  another. 

§  57.  Causes  of  Inflammation. — -The  causes  of  inflmnmatirm  are 
verj  numerous.  Any  influence  which  produces  a  change  in  tlie  walls 
of  the  vessels  in  any  particular  part  of  the  body,  in  the  manner  above 
described,  may  give  rise  to  inflammation.  We  recognise  principally 
the  following  classes  of  inflammation  which  differ  in  point  of  etiologv : 

1.  Inflannnation  from  mechanical  causes  (every  kind  of  trau- 
matism). 

2.  Inflammation  following  the  action  of  extremes  of  temperature 
(thermal  inflammation  ;  burning,  freezing). 

3.  Inflammation  due  to  chemical  causes  (toxic  materials  and  bac- 
teria). 

Under  the  lieading  of  toxic  inflammations  belong  not  only  those 
which  are  produced  by  the  action  of  some  particular  chemical  such  as 
mercury,  sulphuric  acid,  etc.,  but  it  includes  all  inflammations  caused 
by  the  absorption  of  chemically  changed,  decomposed,  or  putrid  sub- 
stances of  a  gaseous  or  liquid  nature.  Inflammations  following  the 
stings  of  insects,  such  as  bees,  and  those  from  the  bites  of  serpents,  all 
come  within  the  class  of  toxic  inflammations.  Advancing  a  step  fur- 
ther, we  come  to  the  infectious  inflammations,  or  those  which  are  pro- 
duced by  the  ingress  of  a  low  order  of  organism  or  fungi — for  exam- 
ple, after  an  injary  to  the  tissues  from  some  traumatism. 

Significance  of  Micro-organisms. — Micro-organisnis^  especially  the 
fungi  schizomycetes  or  bacteria,  are  the  worst  enemies  of  the  surgeon, 


§57.]  INFLAMMATION.  241 

interfering  with  the  normal  healing  process  of  a  wound  and  causing  the 
secondary  wound  diseases.  Hallier,  Pasteur,  Billroth,  Klebs,  Eberth, 
and  particularly  Robert  Koch  and  his  followers,  have  made  great  ad- 
vances in  the  study  of  micro-organisms.  The  honour  of  having  estab- 
lished the  etiology  of  parasitic  infectious  diseases  by  means  of  new 
methods  of  investigation  belongs  chiefly  to  Robert  Koch.  At  the  time 
when  Lister  established  his  antiseptic  and  aseptic  methods  of  oper- 
ating on  the  principle  that  all  infection  was  due  to  bacteria,  which, 
though  not  then  proved,  nevertheless  seemed  probable,  surgery  made 
the  greatest  advance  in  its  history.  Every  inflammatory  process  in  a 
wound,  especially  all  suppuration,  is  due  principally  to  the  presence  of 
micro-organisms,  while  the  injury  itself  plays  only  a  subordinate  part. 

Causes  of  Acute  Suppurative  Inflammation— Significance  of  Bacteria.— The 

investigations  of  Ogston,  Strauss,  etc.,  prove  that  chemical  irritants,  no  matter 
of  what  kind,  do  not  excite  suppurative  inflammation,  but  that  the  latter  can 
only  be  caused  by  micro-organisms.  These  authorities  performed  their  ex- 
periments with  the  most  rigid  antiseptic  precautions.  Strauss,  for  example, 
to  j)revent  accidental  infection  from  the  wound,  made  an  eschar  over  the 
selected  area  of  skin  with  the  Paquelin,  then  through  this  made  his  incision 
with  a  red-hot  knife,  and  introduced  the  long  tip  of  a  glass  tube  containing 
the  sterilised  fluid  into  the  subcutaneous  cellular  tissue,  the  upper  end  of  the 
tube  meanwhile  being  closed  with  a  cotton  plug.  The  glass  tip  was  then 
broken  off  beneath  the  skin,  and  the  fluid  was  forced  out  of  the  tube  and 
under  the  skin  by  blowing  with  the  mouth  over  the  cotton  'plug.  After  tak- 
ing away  the  tube  the  injured  area  of  skin  was  again  cauterised.  After  the 
introduction  in  this  manner  of  such  chemical  irritants  as  sulphuric  acid,  tur- 
pentine, croton  oil,  mercury,  etc.,  only  a  serous,  sero-fibrinous,  or  fibi'ino- 
diphtheritic  inflammation  resulted,  but  never  acute  suppuration.  If  acute 
suppuration  did  occur,  it  was  always  possible  to  demonstrate  the  presence  of 
micro-organisms.  These  authorities  experimented  on  rabbits,  in  which,  to  be 
sure,  a  suppurative  inflammation  is  seldom  caused  by  chemical  irritation. 

But  it  has  recently  been  proved  that  these  statements  are  incorrect.  Orth- 
mann,  Grawitz,  and  De  Barry  have  demonstrated  that  sterilised  chemical  sub- 
stances, such  as  nitrate  of  silver,  oil  of  turpentine,  liq.  ammonii  caustici,  digi- 
toxin,  etc.,  can  produce  acute  suppuration  in  the  subcutaneous  tissue  ;  and 
according  to  Scheuerlen  and  Grawitz,  sterilised  cultures  of  various  micro- 
organisms— in  other  words,  products  of  bacterial  metabolism,  such  as  putres- 
cin,  cadaverin,  penthamethylendiarain,  etc. — act  in  the  same  way.  A  similar 
conclusion  has  been  reached  by  Krynski,  who  experimented  on  dogs  and  rab- 
bits with  the  greatest  care,  partly  by  Strauss's  and  partly  by  Councilman's 
methods,  using  germ-free  (aseptic)  chemical  substances,  the  microbes  which 
cause  suppuration  and  the  products  of  their  metabolism.  Krynski  asserts,  in 
opposition  to  Strauss  and  others,  but  agreeing  with  Brewing  and  Dubler,  that 
oil  of  turpentine  or  mercury  produces  in  dogs  and  rabbits  a  suppuration  which 
is  free  from  bacteria.  A  one-to-five-per-cent.  solution  of  nitrate  of  silver  ex- 
cites the  formation  of  pus  in  dogs,  but  only  an  inflammatory  oedema  in  rab- 
bits. Croton  oil,  bromine,  mineral  acids  (hydrochloric,  sulphuric,  nitric,  and 
17 


242  INFLAMMATION  AJ^D  INJURIES. 

chromic),  organic  acids  (acetic,  carbolic,  lactic,  etc.)  do  not  cause  pus.  In 
dogs  it  is  produced  by  creolin  and  petroleum.  Clean,  mechanically  acting 
agents,  such  as  glass  splinters,  do  not  excite  pus  formation.  The  bacteria  of 
suppvu'ation  (the  staphylococci  and  streptococci),  according  to  Krynski,  will 
only  excite  the  formation  of  pus  in  tissues  which  have  become  pathologically 
changed,  and  they  will  not  develop  in  healthy  tissues,  but  are  desti-oyed,  while 
the  Bacillus  pyogenes  foetidus  will  excite  suppuration  even  in  perfectly 
healthy  tissue.  Krynski  maintains  that  the  Pneumococcus  Friedldnderi  and 
the  Mio^ococcus  2^^'odigiosiis  are  not  pyogenic ;  but  Grawitz  and  De  Barry 
have  established  the  latter's  pyogenic  character  in  the  case  of  dogs,  cats,  rab- 
bits, and  rats.  Sterilised  cultures  of  the  staphylococci  and  streptococci,  or  the 
sterilised  solutions  of  the  products  of  their  metabolism,  will  produce  pus, 
while  sterilised  cultures  of  the  prodigiosus  and  decomposition  extracts  have 
no  such  power.  Although  there  can  be  no  doubt  as  to  the  possibility  of  excit- 
ino-  suppuration  in  the  subcutaneous  tissue  of  animals  bj^  the  experimental 
introduction  of  germ-free  chemical  substances,  yet  it  is  just  as  true  that  sup- 
puration in  man  under  oi'dinary  circumstances  is  caused  by  the  presence  and 
activity  of  micro-organisms,  usually  of  a  specific  variety — viz.,  pyogenic  cocci. 

Immunity  against  Virulent  Staphylococci. — The  investigations  of  Roux, 
Kronacher,  and  others  are  of  great  interest  as  regards  the  acquirement  of 
immunity  against  virulent  staphylococci.  By  the  inoculation  of  sterilised 
cultures  of  the  Staphrjlococcus  pyogenes  aureus  white  mice  can  be  made 
unsusceptible  to  cultures  containing  virulent  cocci. 

Bouchard,  Gley,  and  others  have  shown  that  the  injection  of  the  soluble 
products  of  certain  micro-organisms  such  as  the  Bacillus  jyyocyaneus  has  an 
antiphlogistic  effect  from  paralysis  of  the  vasodilator  nerves,  which  prevents 
dilatation  of  the  vessels  and  emigration  of  the  leucocytes. 

Leber's  Phlogosin— Buchner's  Bacterial  Protein.— Leber's  investigations 
are  extremely  interesting.  He  showed  that  the  micro-organisms,  in  virtue 
of  the  diffusible  products  of  their  metabolism,  can  excite  an  inflammatory 
reaction  through  chemotaxis  at  a  distant  part  of  the  body,  and  from  liquids 
containing  staphylococci  he  isolated  a  crystallisable  body,  phlogosin,  capable 
of  producing  intense  inflammatory  and  necrotic  processes.  Buchner  demon- 
strated that  the  protoplasmic  contents  of  the  bacterial  cells,  the  so-called 
bacterial  protein,  has  a  similar  power  of  exciting  inflammation  and  suppura- 
tion when  separated  from  the  bacterial  cells — in  other  words,  when  these  die 
or  become  diseased.  Buchner  has  so  far  isolated  this  protein  from  seven 
kinds  of  bacteria,  and  proved  its  pyogenic  action. 

Inflammatory  Leucocytosis.— After  invasion  of  the  blood-vessels  with  the 
fungi  of  suppuration  there  is  an  increase  in  the  number  of  leucocytes  in  the 
blood  (inflammatory  leucocytosis).  originating  in  the  spleen,  the  lymph 
glands,  and  bone  marrow.  According  to  Limbeck,  this  is  not  so  miich  a  new 
formation  of  leucocytes  as  a  result  of  the  flushing  out  of  the  above  organs. 
This  inflammatory  leucocytosis  has  an  intimate  connection  with  the  exuda- 
tion accompanying  inflammation,  and  with  the  peptonuria  (Leber,  Hof- 
meister,  Maixner,  etc.). 

As  to  the  influence  of  micro-organisms  upon  the  production  of 
wound  diseases,  etc.,  we  shall  see  later  (§  66)  that  each  separate  wound 


§58.]  INFLAMMATION.  243 

disease  is  caused  hj  a  particular  and  clearly  distinguishable  micro- 
organism. A  short  review  of  the  morphology  and  general  significance 
of  these  will  be  found  in  §  59. 

§  58.  Symptoms,  Diagnosis,  and  Treatment  of  Inflammation. — The 
symptoms  of  inflammation — redness,  swelling,  increased  warmth,  and 
pain — are  easily  explained  by  the  disturbances  of  circulation  which 
have  been  described.  The  redness  and  increased  warmth  are  due  to  the 
distention  of  the  blood-vessels ;  the  swelling  is  likewise  the  result  of 
this,  and  particularly  of  the  exudation.  The  pain  is  caused  by  the 
pressure  of  the  over-filled  vessels  and  of  the  exuded  fluid  upon  the 
sensory  nerves.  A  fifth  symptom  is  the  disturbance  of  function,  and 
is  produced  by  the  change  in  the  circulation  and  the  pressure  of  the 
exuded  fluid  upon  the  motor  nerves,  and  upon  those  governing  secre- 
tion, or  upon  the  cells  themselves.  The  separate  symptoms  naturally 
vary  considerably  in  intensity,  depending  upon  the  severity  of  the 
inflammation,  and  particularly  upon  its  location. 

The  pain  in  inflammation  depends  upon  the  richness  of  the  sensory 
nerve  supply  in  the  inflamed  part,  and  upon  the  amount  of  the  exu- 
date, or  rather  of  the  pressure  which  the  exudate  produces  on  the  sen- 
sory nerves.  Furthermore,  the  amount  of  expansion  that  the  inflamed 
part  is  capable  of  is  an  important  factor.  For  all  these  reasons,  an 
acute  inflammation  located  under  the  fascia,  or  in  the  tips  of  the  fin- 
gers, under  the  nails,  is  particularly  painful,  while  one  involving  mu- 
cous membrane  is  much  less  so. 

The  increased  warmth  is  the  result  of  an  increased  amount  of  blood. 
As  Cohnheim  has  shown,  nearly  double  the  normal  amount  of  blood 
flows  through  a  dog's  paw  when  inflamed.  There  is  an  increased 
amount  of  warmth  brought  to  the  part,  but  the  diminished  rapidity  of 
the  current  causes  an  increase  in  the  loss  of  heat  by  radiation.  There 
has  been  an  erroneous  belief  that  the  inflammatory  focus  was  in  itself 
productive  of  heat,  and  that  the  temperature  at  this  point  was  higher 
than  the  general  body  temperature.  But  ordinarily  it  is  certain  that 
the  temperature  of  the  inflamed  spot  never  exceeds  that  of  the  blood, 
and  generally  is  not  as  high.  Hunter's  law  still  holds  true  to  this  day 
— viz.,  that  the  local  temperature  of  an  inflamed  part  cannot  rise  above 
that  at  the  source  of  the  circulation,  the  heart.  The  redness  is  usually 
dependent  upon  the  richness  in  blood  supply  of  the  inflamed  tissue. 
The  swelling  or  inflammatory  tumefaction  resulting  from  the  exuda- 
tion which  takes  place  varies,  of  course,  with  the  anatomical  structure 
of  the  inflamed  region.  In  general,  the  exudation  takes  place  in  the 
same  way,  but  it  may  manifest  itself  in  many  different  ways,  depend- 
ing upon  whether  it  occurs  in  firm  tissues  like  bone  or  cartilage,  or 


244  INFLAMMATION  AND  INJURIES. 

in  wide-meslied  connective  tissue,  or  in  a  glandular  organ,  or  in  a  cav- 
ity, sucli  as  the  pleural  cavity.  The  inflamniatorj^  exudate  accumulates 
where  it  finds  the  least  resistance. 

As  regards  the  location  of  the  inflammation,  we  distinguisli  between 
a  superficial  and  a  deep  or  parenchymatous  inflannnation  in  the  interior 
of  an  organ.  To  the  superficial  inflammations  belong  those  situated  in 
the  superficial  portions  of  the  body,  in  the  mucous  membranes,  or  the 
surfaces  of  the  great  serous  cavities.  In  a  superficial  inflannnation  the 
inflammatory  exudate  appears  superficially,  and  forms  an  exudate  in 
the  narrow  sense,  while  in  a  parenchymatous  inflammation  the  exudate 
is  spread  out  in  the  tissue  in  question  in  the  form  of  a  so-called  infiltra- 
tion. For  distinguishing  the  location  of  the  parenchymatous  inflam- 
mations more  exactly — as,  for  examjjle,  .those  which  occur  in  the 
glands  or  muscles — a  distinction  is  made  between  a  parenchymatous 
inflammation  in  its  narrow  sense  and  an  interstitial  inflammation,  ac- 
cording as  the  inflammatory  process  affects  more  the  gland  cells,  such 
as  those  making  up  the  parenchyma  of  the  liver,  or  the  connective- 
tissue  stroma. 

The  Varying  Constitution  of  the  Inflammatory  Exudate. — The  cora- 
jDOsition  of  the  exudate  is  of  the  greatest  importance  in  determining  the 
character  of  the  inflammation.  If  the  latter  belongs  to  the  lower  grades 
of  the  process,  or  if,  in  other  words,  there  is  but  a  slight  change  in  the 
walls  of  the  vessels,  the  exudate  is  serous — that  is,  there  is  only  a  small 
amount  of  albumen  and  formed  elements  (blood-corpuscles)  contained 
in  it.  On  the  other  hand,  we  speak  of  a  filjrinous  or  croupous  infiam- 
mation  when  the  exudate  is  rich  in  spontaneously  coagulating  albumen 
— i.  e.,  in  white  blood-corpuscles.  In  a  fibrinous  inflammation  the  dis- 
eased part,  such  as,  for  instance,  the  serous  membrane  or  the  inner 
surface  of  a  joint  capsule,  becomes  covered  with  a  more  or  less  thick 
layer  of  soft  fibrin,  which  gives  it  sometimes  a  smooth  and  sometimes 
a  shaggy  appearance.  The  microscopic  examination  of  such  a  fibrin- 
ous pseudo-membrane  reveals  the  presence  of  an  immense  number  of 
white  blood-corpuscles  scattered  among  threads  of  fil^rin  and  granular 
matter.  This  same  croupous  or  fibrinous  covering  is  found  on  the  sur- 
faces of  mucous  membranes.  According  to  Xeumann,  Gra\vitz,  and 
others,  the  fibrinous  covering  on  the  surface  of  serous  membranes  is  the 
result  of  a  fibrinoid  degeneration  of  the  connective  tissue,  but  Ziegler 
and  others  regard  it  as  the  fibrin  formed  in  the  exudate.  In  tubercular 
inflammation  there  is  a  marked  hyaline  degeneration  of  the  connective 
tissue.  Between  the  two  main  types  of  serous  and  fibrinous  inflamma- 
tions there  are,  of  course,  a  number  of  intermediate  forms  which  are 
designated  as  sero-fibrinous  exudates. 


§58.]  IXFLAMMATION.  245 

Suppurative  Exudate. — The  third  kind  of  exudate  is  the  suppura- 
tive or  purulent,  consisting  of  a  thick,  milky,  or  cream-like,  non-coagu- 
lable  lluid,  generally  without  odour,  and  briefly  designated  by  the  name 
of  pus.  Microscopically,  this  is  a  colourless  fluid  containing  a  vast  quan- 
tity of  cells,  "  pus  cells,"  and  a  few  red  blood-corpuscles.  According 
to  Gravfitz,  the  suppurative  inflammation  is  only  a  more  advanced 
grade  of  inflammation,  while  Weigert,  on  the  other  hand,  maintains 
that  it  represents  qualitatively  a  particular  kind.  Strieker  and  Eeck- 
linghausen  think  that  suppuration  is  not  exclusively  a  melting-down 
process  of  the  tissues  without  coagulation,  produced  by  means  of 
emigrated  leucocytes,  but  rather  that  a  proliferation  of  the  fixed 
connective-tissue  elements  also  plays  an  important  part.  There  is 
always  an  enlargement  and  multiplication  of  the  fixed  connective- 
tissue  cells  in  the  vicinity  of  the  suppurative  focus.  By  the  pro- 
liferation of  the  fixed  cells  a  large  number  of  young  cells  are  formed 
which  correspond  in  appearance  to  the  mononuclear  white  blood- 
corpuscles. 

Pus  is  a  product  composed  of  emigrated  leucocytes  and  the  varied 
offspring  of  the  connective-tissue  cells.  Every  suppurative  inflamma- 
tion is  to  be  considered  as  a  severe  inflammation,  and,  as  we  have  indi- 
cated, it  is  in  the  main  of  an  infectious  nature — that  is,  it  is  the  result 
of  an  infection  by  bacteria.  But  we  have  seen  that  sometimes  even 
germ-free  chemical  substances  may  j)roduce  suppuration  (Grawitz,  De 
Barry,  Krynski,  etc.). 

Between  the  extreme  types  of  purulent  and  fibrinous  inflammation 
there  are  also  many  intermediate  gradations  of  the  process  which  are 
known  as  fibrino-purulent  inflammations.  If  the  suppurative  process 
is  sharply  defined  in  the  tissues,  there  results  what  is  called  an  abscess ; 
but  if  the  process  is  more  diffuse,  it  is  spoken  of  as  suppurative  infil- 
tration. An  abscess — i.  e.,  a  cavity  filled  with  pus — results  from  a  sup- 
purative infiltration  which  liquefies  and  dissolves  the  affected  tissues. 
A  loss  of  substance  in  the  superficial  portions  of  the  body,  accom- 
panied by  the  formation  of  pus  and  breaking  down  of  the  granulation 
tissue,  constitutes  an  ulcer.  A  collection  of  pus  in  a  cavity  is  called  a 
purulent  effusion,  while  a  purulent  secretion  from  a  mucous  membrane 
is  called  a  purulent  catarrh. 

Haemorrhagic  Exudate.— The  fourth  kind  of  exudate  is  the  hsemor- 
rhagic — i.  e.,  the  serous,  fibrinous,  or  purulent  exudate  contains  such 
an  amount  of  red  blood-corpuscles  that  it  becomes  red  in  colour.  The 
hsemorrhagic  exudate  is  a  symptom  of  serious  alterations  in  the  walls 
of  the  capillaries,  such  as  takes  place  in  certain  constitutional  diseases, 
or  as  a  result  of  a  systemic  infection  through  bacteria. 


246  INFLAMMATION  AND  INJURIES. 

Ichorous  Exudate. — The  decomposed,  foul-smelling  exudate  accom- 
panying puti-efaction  is  designated  as  ichorous  or  putrid.  It  has  a 
grey  or  greyish-green,  l)rown,  or  dirty  yellow  colour. 

Croupous  or  Diphtheritic  Inflammation. — The  so-called  croupous  or 
diphtheritic  intlaamiation,  or  the  crou[)ous  or  diphtheritic  exudate,  is 
the  result  of  the  combination  of  an  inflammatory  process  with  another 
of  a  different  nature.  Croupous  inflammation  of  a  mucous  membrane 
is  characterised  by  the  formation  of  a  skin-like,  fibrinous  exudate 
(croupous  membrane)  clinging  to  its  surface  and  taking  the  place  of 
the  original  epithelial  covering  which  has  perished.  This  croupous 
membrane  consists  of  a  network  of  fibrin  fibres  containing  leucocytes 
and  the  remains  of  the  epithelium.  In  diphtheria  the  death  of  tissue 
extends  deeper,  and  the  process  is  a  combination  of  necrosis  and  fibrin- 
ous inflammation.  The  affected  portion  of  the  mucous  membrane  is 
changed  into  a  pecuhar  greyish-white,  tough  mass,  which  comes  away 
in  membrane-like  layers  (diphtheritic  pseudo-membrane),  and  produces 
corresponding  losses  of  substance  (diphtheritic  ulcers).  The  tissues 
destroyed  by  the  inflammatory  process  coagulate  in  flaky  or  stringy 
masses,  which  signifies  serious  structural  changes  involving  the  blood- 
vessels and  surrounding  tissue,  with  here  and  there  stasis  and  throm- 
bosis. Cohnheim  and  Weigert  have  given  to  this  form  of  localised 
tissue  death  the  name  of  coagulation  necrosis  (Neumann's  fibrinoid 
degeneration).  Weigert's  investigations  show  that  coagulation  necro- 
sis is  a  death  by  coagulation  of  the  tissue  or  cells  in  a  necrotic  area 
through  which  a  small  amount  of  lymph  flows.  The  lymph,  with  its 
fibrinogen,  penetrates  the  cells  and  coagulates  with  the  fibrino-plastin 
witliin  the  cells.  Coagulation  necrosis  is  a  frequent  accompaniment 
of  inflammatory  processes,  of  embolic  infarcts,  and  of  the  so-called 
waxy  degeneration  of  muscles. 

Extension  of  an  Inflammation.— The  inflammatory  process  spreads 
by  infiltration  of  the  connective-tissue  spaces,  the  muscular  sheaths,  and 
the  vascular  channels  with  the  inflammatory  exudate— in  other  words, 
from  a  circumscribed  spot  of  suppuration  (abscess)  there  may  develop 
a  spreading  cellulitis.  The  inflammation  also  spreads  through  the 
lymph  spaces,  the  main  lymphatics,  and  the  blood-vessels.  When  the 
exciting  cause  of  the  inflainmation  gets  into  the  circulatory  system, 
the  original  local  disturbance  becomes  a  general  systemic  disease  in- 
volving the  whole  organism.  The  poison— so  to  designate  briefly  the 
noxious  element— passes  through  the  lymph  channels  to  the  nearest 
lymphatic  glands,  exciting  there  also  inflammation,  and  finally  sup- 
puration. These  diseased  glands  then  become  a  fresh  source  of  in- 
flammation, which  in  this  manner  spreads  farther  and  farther  through 


§  58.]  INFLAMMATION.  247 

the  body  and  pi-ogressively  affects  more  of  its  organs.  Such  a  meta- 
static inflammatory  and  suppurative  process  will  be  again  referred  to 
under  the  heading  of  pyajmia,  by  which  we  mean  a  poisoning  of  the 
blood  by  the  microbes  of  suppuration  and  the  products  of  their  meta- 
bolism. By  the  spreading  of  the  micro-organisms  and  the  products  of 
their  metabolism  throughout  the  circulation,  and  the  production  of  cir- 
cumscribed foci  of  inflammation  in  different  organs,  a  general  systemic 
infection  accompanied  by  fever  results  (see  §  62,  Fever).  We  shall 
learn  later  how  prominently  the  fungi  are  concerned  in  the  extension 
of  the  inflammation  and  in  the  occurrence  of  the  systemic  infection. 
Clinical  observations  and  experiments  on  animals  seem  to  show  that 
local  metastatic  foci  of  suppuration  are  particularly  liable  to  occur 
when  there  exists  a  general  weakness  or  impairment  of  vitality  of  the 
whole  organism  (Rinne).  The  soil  for  the  lodgment  of  the  micro- 
organisms is  made  ready  for  them  in  advance  by  the  products  of  their 
metabolism  which  get  into  the  circulating  blood. 

Duration  of  an  Inflammation. — According  as  the  inflammation  lasts 
a  shorter  or  longer  time  it  is  spoken  of  as  acute  or  chronic.  The 
manifestations  of  an  acute  inflammation  have  been  sufficiently  de- 
scribed above.  The  acute  inflammation  often  becomes  a  chronic  one, 
or  the  latter  begins  from  the  first  as  such.  The  transition  or  inter- 
mediate types  between  an  acute  and  chronic  inflammation  are  known 
as  subacute  inflammations.  Tubercular  and  syphilitic  inflammations 
are  the  most  important  forms  of  the  chronic  class.  The  true  type  of 
chronic  inflammation  is  the  productive  or  adhesive  inflammation,  which 
leads  to  new  formation  of  tissue,  to  adhesions  and  thickenings  of  every 
description,  depending  upon  the  anatomical  structure  of  the  affected 
organ,  such  as  a  joint,  bone,  periosteum,  or  connective  tissue.  We  shall 
describe  in  their  proper  place  the  special  symptoms  of  inflammations 
involving  the  different  organs. 

Origin  of  the  Pus-corpuscles. — The  so-called  pus-corpuscles  which  are 
found  in  the  inflammatory  effusion  are  made  up,  in  part  at  least,  of  the  white 
blood-corpuscles  which  have  wandered  out  from  the  interior  of  the  vessels. 
Whether  all  the  pus-corpuscles  are  emigrated  blood-cells,  or  whether  pus- 
cells  may  originate  otherwise— as,  for  instance,  from  the  fixed  tissue  cells— or 
whether  pus-cells  may  multiply  by  fission  or  division,  are  all  questions  to 
which  various  answers  have  been  given.  Some  have  considered  it  impos- 
sible that  the  enormous  number  of  pus-corpuscles  found  in  a  large  inflam- 
matory process,  like  a  phlegmon  or  a  large  granulating  wound,  should  all 
be  derived  from  the  blood.  Cohnheim  was  right  in  directing  attention  to 
the  fact  that  the  veins  and  capillaries  contain  comparatively  large  numbers 
of  white  blood-corpuscles,  and  that  the  number  of  these  white  cells  is  much 
increased  during  inflammatory  diseases.  The  white  blood -corpuscles  which 
go  to  form  pus-cells  are  constantly  replaced  by  an  increased  activity  of  the 


24S  INFLAMMATION  AND  INJURIES. 

spleen  and  lymphatic  glands.  Bottcher,  Strieker  and  his  followers,  Reck- 
linghausen, Grawitz,  and  others  differ  from  Cohnheim  in  his  view  that  the 
blood  is  the  sole  source  of  the  pus-cells,  and  atlirni  that  the  latter  originate 
also  from  the  fixed  tissue  cells.  These  authors  believe  that  the  cellular  ele- 
ments of  pus  consist  partly  of  emigrated  leucocytes  and  partly  of  the  off- 
spring of  the  fixed  connective-tissue  cells.  Grawitz  affirms  that  the  sti'oma 
or  fibrous  portion  of  the  tissues  takes  on  a  cellular  change  and  becomes  a 
third  source  of  the  pus-corpuscles.  Recklinghausen  has  demonstrated  that 
pus-cells,  if  kept  in  a  warm  and  moist  medium  while  being  examined,  will 
change  their  form  and  go  through  the  same  amoeboid  movements  as  the 
white  blood-cells. 

Number  of  Pus-cells  in  Pus.— Chelchowski  determined  the  number  of  pus- 
corpuscles  by  means  of  Mallassey-Verick's  apparatus  in  twenty  different 
cases  of  suppuration.  For  diluting  the  pus,  he  employed  a  weak  solution  of 
common  salt  or  Toison's  fluid  (methylviolet).  The  number  of  pus-cells  in 
one  cubic  millimetre  of  pus,  according  to  Chelchowski,  varied  between  four 
hundred  thousand  and  one  million  six  hundred  thousand.  The  exudate  con- 
tained from  ten  to  fifteen  times  more  leucocytes  than  the  transudate.*  The 
suppurative  character  of  a  fluid,  drawn  off  by  aspiration,  can  only  be  recog- 
nised macroscopically  when  it  contains  at  least  from  forty  to  sixty  thovisand 
pus-cells  to  the  cubic  millimetre,  and  consequently  it  is  very  possible  for  a 
comparatively  large  amount  of  pus  to  be  present  in  a  tiuid  without  its  being 
noticed. 

Composition  of  Pus. — Pus  consists  of  the  above-mentioned  cellular  ele- 
ments, which  are  called  pus-corpuscles,  and,  in  addition,  of  pus  serum.  If 
pus  is  allowed  to  stand  for  a  time  in  a  test  tube,  it  separates  into  two  layers, 
the  upper  bright  yellow  layer  being  the  pus  serum,  and  the  lower  forming  a 
thick  deposit  made  up  principally  of  pus-coi'puscles.  The  pus  serum  cor- 
responds to  the  plasma  of  the  blood  which  is  its  source,  but  often  differs 
from  it  chemically  very  materially.  There  are  ten  to  sixteen  per  cent,  of 
solid  elements  in  pus,  and  five  to  six  per  cent,  of  ash.  The  gases  consist  of 
nitrogen  and  carbonic  acid ;  ordinarily  there  is  no  oxygen  or  hydrogen. 
There  is  generally  a  somewhat  greater  amount  of  sodium  and  potassium  than 
in  blood  serum.  The  albuminous  substances  in  pus  consist  chiefly  of  para- 
globulin,  albuminate  of  potassium,  serum  albumen,  myosin,  leucin,  and 
tyrosin.  The  formed  constituents,  in  addition  to  the  pus-corpuscles,  include 
micro-organisms,  and  often  red  blood-cells,  fibrin,  fat  droplets,  fat  and 
cholesterin  crystals,  particles  of  necrotic  tissue,  etc.  Sterilised  pus  serum 
has  nearly  the  same  toxic  action  as  the  sterilised  products  of  the  Staphylo- 
coccus aureus  and  albus  (page  .328)  :  repeated  injections  give  rise  to  chronic 
marasmus  (Nasmoki).  Pus  which  contains  fungi  usually  does  not  coagulate, 
although  large  numbers  of  leucocytes  may  be  present.  This  is  due  to  the 
fact  that  there  is  no  fibrinogen  in  the  pus,  or  rather  that  the  micro-organisms 
change  the  fibrinogen  in  the  exuded  ])]asma  into  peptone. 

Growth  of  Bacteria  in  Germ-free  Pus. — According  to  Eichel,  germ-free 
pus  contains  a  substance  which  is  deleterious  for  many  kinds  of  bacteria,  and 
small  quantities  of  the  Staphylococcus  pyogenes  aureus  and  the  anthrax 
bacillus  will  perish  after  about  five  days,  but  thel  sti'eptococci  are  not  harmed. 

*  In  the  sense  of  a  passive  effusion,  as  in  cardiac  dropsy. 


§  58.]  INFLAMMATION.  249 

By  the  addition  of  putrefactive  bacteria  or  the  products  of  their  metabolism 
this  deleterious  property  is  increased.  The  reaction  of  pus  which  has  recently 
been  taken  from  the  body  is  alkaline,  but  it  becomes  acid  after  long  exposure 
to  the  air. 

Coloured  Pus. — Green  or  blue  pus  is  sometimes  found  instead  of  the  usual 
creamy,  more  or  less  yellow-coloured  variety.  This  discolouration  is  usually 
brought  about  by  the  presence  of  the  bacillus  pyocyaneus  (see  pages  330,  331). 
0.  Grube  and  Ferchmin  have  seen  fourteen  cases  of  bright  red  pus.  The 
cinnabar  colour  is  due  to  a  specific  bacillus  (see  page  331 1.  Orange-coloured 
pus  occurs  as  the  result  of  the  admixture  with  crystals  of  hsematoidin. 

Outcome  of  an  Inflammation. — In  considering  the  outcome  of  an  in- 
flammation, the  secondary  conditions  that  follow  must  be  distinguished 
from  the  purely  local  processes  at  the  seat  of  the  inflammation.  As 
regards  the  system  at  large,  the  main  purpose  of  inflammation  is  to  do 
away  with  the  causes  which  give  rise  to  the  inflammation,  accomplish- 
ing this  by  increased  metabolism,  rapidity  of  circulation,  and  transuda- 
tion. The  processes  which  take  place  in  an  inflammation  combat  its 
causes  in  an  efficient  way,  and  try  to  make  reparation  for  the  damaging 
effects  that  it  produces  (Leber,  Arnold).  In  many  cases  the  inflamma- 
tion is  not  capable  of  removing  the  causation  of  the  disease.  Death 
may  occur  at  any  stage  of  the  inflammation,  but  especially  when  the 
inflammatory  process  is  at  its  height,  as  a  result  of  a  general  systemic 
infection  with  fever,  due  to  the  primary  local  inflammation.  We  shall 
learn  in  §  62  about  the  significance  of  fever  and  its  dangers  for  the 
organism.  From  a  prognostic  standpoint,  the  location  of  the  inflam- 
mation is  of  the  greatest  importance.  A  subcutaneous  abscess  is  by 
no  means  as  dangerous  to  life  as  a  very  minute  collection  of  pus  in  the 
bones  of  the  skull,  the  meninges,  or  in  the  brain,  the  medulla  oljlongata, 
etc.  The  age  and  constitution  of  the  patient  are  likewise  important 
factors. 

If  we  take  a  purely  local  view  of  the  outcome  of  an  inflammation, 
the  worst  that  can  occur  is  gangrene  or  necrosis — i.  e.,  death  of  the 
affected  tissues.  In  its  various  gradations  this  is  a  very  frequent  result 
of  an  inflammation,  and  is  due  either  to  complete  stasis  in  the  vessels, 
followed  by  coagulation  of  the  blood  which  they  contain,  or  to  pi-es- 
sure  of  the  exudate  on  the  surrounding  tissue.  Furthermore,  in  a 
localised  death  of  tissue,  constitutional  conditions,  such  as  diabetes  or 
old  age,  play  a  very  important  part.  We  shall  return  to  the  discussion 
of  localised  death  of  tissue  (gangrene,  necrosis,  or  mortification)  in  an- 
other chapter.  It  will  only  be  stated  now,  that  in  general  the  extent 
of  the  inflammatory  necrosis  varies  greatly,  depending  upon  the  inten- 
sity and  extent  of  the  inflammation.  We  shall  see  that  the  influence 
of  micro-organisms,  such  as  single  groups  of  bacteria,  is  a  prominent 


250  INFLAMMATION   AND   INJURIES. 

factor  in  the  production  of  gangrene.  The  capabiUty  on  the  part 
of  the  tissues,  and  especially  of  the  vessels,  of  withstanding  gangrene 
varies  greatly  with  the  portion  of  the  body  which  is  affected  and  with 
the  individual.  The  most  favourable  outcome  of  an  inllammation  is  a 
complete  restitutio  ad  integrum — a  perfect  restoration  to  the  original 
condition — which  of  course  is  most  frequently  observed  after  an  inllam- 
mation of  a  mild  type  in  which  the  exudate  has  been  scanty  and  chiefly 
serous.  The  disappearance  of  the  phenomena  of  inflammation  begins 
as  soon  as  the  circulatmg  blood  has  restored  the  walls  of  the  blood- 
vessels to  their  normal  condition,  and  when  this  has  taken  place  the 
exudation  ceases.  The  fluid  portion  of  the  exudate  is  absorbed  by  the 
lymph  vessels,  likewise  the  white  blood-corpuscles  and  fibrin,  after  they 
have  in  part  undergone  a  fatty  degeneration.  The  red  blood-cells  lose 
their  colouring  matter,  and  gradually  become  disintegrated.  The  fixed 
tissue  cells  which  have  been  damaged  by  the  infiammatory  irritation 
recover  after  the  restoration  of  their  normal  nutrition,  and  by  degrees 
a  comj^lete  restitution  takes  place.  Sometimes,  however,  after  absorp- 
tion of  the  fluid  the  formed  or  solid  elements  of  the  exudate  remain 
behind  as  a  light  yellow,  caseous  mass,  which,  by  a  reactive  inflamma- 
tion, becomes  encapsulated  as  a  cheesy  nodule,  like  a  foreign  body. 
Under  such  conditions  complete  absorption  often  does  not  occur,  and 
finally  a  deposition  of  salts  of  lime  takes  place,  forming  a  firm,  calcare- 
ous concretion. 

If  the  inflammatory  process  is  more  severe,  and  if  there  is  localised 
death  of  tissue,  the  absorption  of  the  exudate  and  the  necrotic  soft 
parts  takes  place  in  a  similar  manner — i.  e.,  by  absorption  of  the  fluid 
and  fatty  emulsion  of  the  solid  elements.  Small  portions  and  granules 
of  tissue,  in  case  they  are  not  taken  up  by  the  lymph  channels,  are 
seized  by  the  cells  which  have  wandered  out  of  the  vessels,  and  which 
in  this  way  become  granular  cells.  If,  as  the  result  of  an  inflammation, 
a  portion  of  bone  has  become  necrotic,  the  dead  piece  of  bone  or 
sequestrum  is  separated  from  the  living  bone  by  a  suppurating  line  of 
demarcation  (see  §  106).  The  pus  formed  during  an  inflammatory  pro- 
cess near  the  surface  of  the  body  may  break  through  spontaneously,  or 
be  removed  artificially  by  operative  measures,  such  as  incision,  etc. 

There  is  the  danger  in  all  infectious  inflammations,  or  those  caises 
of  suppuration  which  are  due  to  micro-organisms,  that  the  inflamma- 
tion may  become  the  starting-point  for  a  general  infection.  There- 
fore, whenever  it  is  possible,  operative  measures  should  be  undertaken 
at  an  early  period  to  provide  a  way  of  escaj^e  for  the  exudate,  for 
otherwise  the  inflammation  and  suppuration  may  spread,  resulting  in 
an  extensive  infiltration  or  phlegmon,  which  may  break  through  into 


§58.]  INFLAMMATION.  251 

an  important  organ,  sucli  as  a  joint,  the  cranial  cavity,  abdominal  cav- 
ity, etc.  Moreover,  the  micro-organisms  that  cause  the  inflammation 
are  scattered  about  by  the  lymph-  and  blood-vessels.  It  must  always 
be  borne  in  mind  that  products  are  constantly  being  formed  in  an 
infectious  inflammation  which  are  capable  of  producing  further  inflam- 
mation in  the  surrounding  parts  and  in  widely  separated  organs.  The 
bacteria,  and  the  products  of  metabolism  and  decomposition  which 
they  cause,  are  here  again  the  causes  of  the  secondary  inflammatory 
processes.  As  a  result,  then,  of  infectious  inflammations,  bacteria  may 
be  deposited  in  large  numbers  in  different  internal  organs,  causing  sec- 
ondary so-called  metastatic  abscesses. 

Scar  Formation. — If  a  defect  or  loss  of  substance  results  from  a 
severe  inflammation  with  necrosis,  this  is  remedied  to  a  greater  or  less 
extent  by  a  new  production  of  connective  tissue,  which  is  then  called 
cicatricial  tissue.  Scar  formation  is  to  be  looked  upon  as  an  inflam- 
matory process  which  is  productive  in  character.  A  germinal  or  granu- 
lation tissue,  as  it  is  called,  develops,  consisting  only  of  round  cells 
with  a  very  small  amount  of  intercellular  substance ;  this  granulation 
tissue  then  gradually  changes  into  fibrous  connective  tissue,  which 
makes  up  the  cicatrix.  I  used  to  believe,  as  Cohnheim  did,  that  the 
new-formed  connective  tissue,  the  granulation  and  cicatricial  tissue,  was 
chiefly  derived  from  the  emigrated  leucocytes,  which  increase  in  size 
when  the  new  blood-vessels  developed  among  them  and  became  large, 
irregular-shaped  cells  (fibroblasts).  But  some  recent  investigations 
have  made  me  conclude  that  the  leucocytes  at  the  inflammatory  focus 
are  unflt  for  making  new  connective  tissue  and  healing  up  the  wound, 
and  I  am  now  convinced  that  they  gradually  disappear,  partly  by  wan- 
dering into  the  lymphatic  vessels  and  being  carried  off  in  the  lymph 
current,  and  partly  by  wandering  into  other  localities  and  disintegrat- 
ing and  being  taken  up  by  the  fixed  cells  of  the  part  (Baumgarten, 
Zahn,  Marchand,  etc.).  Ziegler  has  also  expressed  the  same  view. 
The  newly  formed  connective  tissue,  therefore,  is  in  reality  produced 
by  a  growth  of  the  fixed  connective-tissue  cells  (Baumgarten,  Marchand, 
etc.).  Marchand  has  proposed  to  designate  the  leucocytes  originating 
from  the  blood  and  lymphatics  as  exudation  cells,  in  contradistinction 
to  the  granulation  or  true  formative  cells  which  are  derived  from  the 
tissues.  The  formative  cells  get  their  nourishment  from  the  protoplasm 
of  the  leucocytes,  as  I  have  mentioned  above.  Sherrington,  Ballance, 
Shattuck,  and  others  maintain  that  the  plasma  cells  are  the  ones  chiefly 
concerned  in  the  formation  of  cicatricial  tissue  (see  also  §  61). 

Regeneration  of  the  Tissues. — Simultaneously  with  the  formation  of 
the  D-ranulation  or  cicatricial  tissue  there  is  a  prohferation  of  the  fixed 


252  INFLAMMATION  AND  INJURIES. 

(specific)  cells  in  the  neighbourhood  for  the  purpose  of  restoring  the 
cells  that  make  up  the  particular  structure.  Epithelium  gives  rise  to 
epithelium  ;  muscle  cells  form  muscular  fibres,  though  in  a  very  limited 
amount ;  periosteal  and  medullary  cells  make  bone,  etc.  The  power  of 
regeneration  possessed  by  the  different  tissues  varies  very  greatly,  as 
we  shall  see.  The  skinning  over  or  covering  of  a  loss  of  substance  in 
the  skin  with  epidermis  is  brought  about  by  the  cells  of  the  rete  Mal- 
pighii  and  sebaceous  glands.  Reference  is  made  to  §  61  for  the 
description  of  the  various  phenomena  in  scar  formation  and  regenera- 
tion in  the  diiierent  tissues  (microscopic  phenomena  in  the  healing  of 
a  wound),  and  to  §§  87  and  88  (Injuries  of  Soft  Parts).  For  the  pro- 
cess of  healing  of  fractures  see  §  101. 

The  Healing  of  a  Foreign  Body  into  a  Wound.— If  the  inflanimation  is 
caused  by  the  entrance  into  the  tissues  of  a  solid  foreign  body,  the  latter  may 
completely  heal  into  the  tissues,  as  we  shall  often  have  the  opportunity  of 
observing ;  and  this  will  occur  the  more  readily  the  more  free  the  body  is 
from  dirt,  dust,  bacteria,  products  of  decomposition,  etc.  We  know  that  silk 
sutures,  silver  wire,  bullets,  etc.,  heal  up  in  a  wound  in  this  way  without  giv- 
ing rise  to  any  reaction.  Foreign  bodies  which  have  thus  become  enclosed 
often  change  their  location  later  on,  and  in  their  wanderings  may  make 
their  appearance  beneath  the  skin  in  another  portion  of  the  body.  Large, 
soft  foi-eign  bodies  are  completely  absorbed  in  the  way  described  above.  I 
implanted,  under  antiseptic  precautions,  lai'ge  fresh  pieces  of  liver,  spleen, 
lung,  and  even  entire  kidneys  of  rabbits,  in  the  peritoneal  cavities  of  other 
rabbits,  and  found  that  they  became  absorbed  without  producing  peritonitis. 
I  also  used  similar  specimens  which  had  been  hai'dened  in  absolute  alcohol, 
and  with  the  same  results.  The  portions  of  tissue  were  invaded  by  vast 
numbers  of  wandering  cells  and  slowly  liquefied. 

Hallwachs,  Rosenbergei',  Salzer,  and  others  have  recently  studied  the  sub- 
ject of  the  encapsulation  of  foreign  bodies,  and  Salzer  says  that  those  which 
are  smooth  and  solid  become  enclosed  in  a  delicate  connective-tissue  capsule, 
while  the  porous,  fibrous,  rough  foreign  bodies  are  most  apt  to  heal  into  the 
scar  tissue  with  the  formation  of  very  thick  layers  of  connective  tissue. 

Diagnosis  of  Inflammation, — In  the  diagnosis  of  inflammation — i.  e., 
of  the  four  above-described  cardinal  symptoms,  redness,  swelling,  heat, 
and  pain — we  make  special  use  of  inspection  and  palpation  of  the 
affected  part  in  case  it  can  be  seen  and  touched.  If  the  inflammation 
is  located  on  the  outer  surface  of  the  body  the  diagnosis  is  simple,  but 
it  is  more  difiicult  if  the  inflammation  is  situated  more  deeply.  By 
palpation  of  the  inflamed  tissues  we  attempt  to  determine  whether  the 
inflammatory  focus  contains  pus — i.  e.,  whether  it  "  fluctuates  "  or  not. 
Every  fluid,  and  consequently  pus  or  serum,  contained  in  a  cavity  hav- 
ing yielding,  elastic  walls  will  give  fluctuation  or  a  wave  movement 
when  the  fluid  in  this  cavity  is  set  in  motion  by  intermittent  pressure 


§  58.]  INFLAMMATION.  253 

with  the  index  or  middle  finger.  The  detection  of  fluctuation  is  of 
the  greatest  pi-actical  importance.  If  the  pus  is  contained  within  fii-m, 
unyielding  walls,  such  as  bone,  or  in  deeply  situated  tissue  with  thick- 
ened I'igid  walls,  fluctuation  cannot  be  made  out.  Furthermore,  it 
must  not  be  confused  with  the  pseudo-fluctuation  manifested  upon  23al- 
pation  of  soft  elastic  parts ;  but  a  little  experience  will  soon  teach  the 
distinction  between  the  fluctuation  of  an  elastic  cavity  filled  with  fluid 
and  the  pseudo -fluctuation  of  soft  elastic  tissues  such  as  the  muscles  of 
the  thenar  eminence,  soft  fatty  tumours,  etc.  Puncture  with  an  aspi- 
rating syringe  is  an  exceedingly  useful  diagnostic  measure  for  de- 
termining the  nature  of  the  contents  of  an  inflammatory  focus  (see 
page  74). 

We  also  employ  the  sense  of  hearing  in  the  diagnosis  of  an  inflam- 
mation by  noting,  for  example,  whether  any  friction  sound  is  produced 
by  the  rubbing  together  of  two  opposed  inflamed  surfaces.  Hueter 
has  constructed  instruments  analogous  to  the  stethoscope  used  in  the 
diagnosis  of  diseases  of  the  thoracic  viscera ;  they  are  a  dermatophon, 
an  osteophon,  and  a  myophon,  for  the  diagnosis  of  surgical  diseases  of 
the  skin,  bones,  and  muscles  respectively,  and  they  consist  of  an  elastic 
tube  fitted  to  an  ear-piece.  We  shall  refer  to  this  apparatus  in  diseases 
of  bone,  but  it  may  be  said  here  that  hitherto  it  has  not  been  brought 
into  general  use. 

The  febrile  disturbance  accompanying  an  inflammation  is  deter- 
mined by  accurate  measurement  of  the  body  heat  by  means  of  a  ther- 
mometer placed  in  the  axilla,  or,  better,  in  the  rectum  (see  §  62, 
Fever), 

Among  other  aids  to  diagnosis  I  should  mention  the  probe,  which 
is  used  to  ascertain  the  direction  and  length  of  a  fistulous  tract,  or  the 
presence  of  a  foreign  body.  There  are  also  instruments  designed  for 
special  organs,  such  as  the  urethra,  bladder,  stomach,  etc.,  and  a  gi-eat 
number  of  contrivances  for  inspection  of  the  nose,  larynx,  bladder, 
eye,  etc. 

These  general  remarks  will  be  sufiicient  until  we  return  to  the  diag- 
nosis of  inflammations  of  the  separate  parts  of  the  body. 

Treatment  of  Inflammation. — At  present  we  can  only  deal  briefly 
with  the  treatment  of  inflammation,  as  we  shall  have  to  come  back 
to  the  subject  in  detail  for  each  separate  part  of  the  body.  From  a 
prophylactic  standpoint  it  is  best  to  treat  every  injury,  no  matter  how 
trifling  it  may  be,  on  antiseptic  principles,  after  the  manner  described 
in  a  former  chapter.  In  general,  the  treatment  of  an  acute  inflamma- 
tion consists  in  the  use  of  suitable  antiphlogistic  measures,  particularly 
the  proper  position  of  the  inflamed  part,  such  as  elevation  in  the  case 


254  INFLAMMATION  AND  INJURIES. 

of  an  extremity,  in  the  application  of  ice,  and  in  the  prompt  evacuation 
of  the  pus  or  inliltrating  exudate  bj  incision. 

Blood-letting  by  leeches,  cupping,  and  scarification  used  to  be  much 
in  vogue  for  diminishing  the  amoimt  of  l:)lood  contained  in  an  iniiamed 
portion  of  the  body,  but  now  this  practice  has  very  properly  been  given 
up.  The  counter-irritation  method  of  treatment  by  cutaneous  irritants, 
such  as  the  moxa,  issue,  red-hot  iron,  painting  with  tincture  of  iodine, 
and  the  application  of  vesicants,  is  also  old-fashioned.  It  Avould  re- 
quii-e  too  much  space  to  give  the  outlines  of  treatment  for  inflamma- 
tion according  to  the  location  and  causes  of  the  latter,  and  it  can  be 
done  more  satisfactorily  in  the  discussion  of  the  treatment  of  inflam- 
mations of  the  separate  organs.  The  treatment  of  the  general  febrile 
disturbance  due  to  inflammation  will  be  considered  in  the  treatment  of 
fever  (§  62). 

§  59.  Morphology  and  General  Significance  of  Micro-organisms. — By 
Tnicro-organisms  or  microbes  is  understood  a  class  of  minute  living 
organisms  which  belong  to  the  lowest  forms  of  plant  life  or  stand  on 
the  border  line  between  plants  and  animals.  The  majority  of  the  mi- 
cro-organisms have  a  diameter  of  only  about  one  micromillimetre  or 
less.  They  multiply  with  extreme  rapidity,  and  are  able  to  live  in 
widely  differing  degrees  of  temperature,  some  in  acid  and  others  in 
alkaline  solutions  of  simple  compounds  (with  the  exception  of  carbon 
dioxide),  as  well  as  of  more  complex  nourishing  substances. 

The  micro-organisms  play  a  very  important  part  in  the  economy  of 
nature.  They  excite  fermentation  and  decomposition,  and  are  parasites 
.in  living  plants,  animals,  and  man,  causing  in  some  cases  disease  and 
death.  By  fermentation  and  decomposition  the  micro-organisms  dis- 
integrate considerable  amounts  of  organic  material  in  a  short  period  of 
time  with  the  evolution  of  gas.  The  change  of  sugar  into  lactic  acid 
(sour  milk),  the  lactic  into  butyric  acid,  and  alcohol  into  acetic  acid, 
are  all  processes  of  fermentation  caused  by  micro-organisms.  We  make 
use  of  micro-organisms  in  the  preparation  of  many  alimentary  sub- 
stances, such  as  bread,  cheese,  beer,  wine,  etc.,  while  on  the  other  hand, 
as  a  result  of  the  fermentative  and  putrefactive  action  of  these  low 
orders  of  organisms,  our  food  may  be  rendered  unfit  to  eat. 

Micro-organisms  also  produce  poisonous  matters  (ptomaines,  tox- 
ines)  which  are  dangerous  to  the  health  and  life  of  man.  NnUaerous 
acute  and  chronic  inflammations,  particularly  the  surgical  diseases  of 
wounds,  are  due  to  the  presence  of  micro-organisms. 

Evidence  of  the  Bacterial  Origin  of  many  Infectious  Diseases,  especially 
the  Diseases  of  Wounds. — Under  normal  conditions  we  find  no  micro-organ- 
isms in  the  blood  and  internal  organs  of  healthy  human  beings  and  animals  ; 


§59.]  MICRO-ORGANISMS.  255 

this  has  been  proved  beyond  a  doubt  by  Meissner  and  many  other  investi- 
gators. On  the  other  hand,  we  observe  in  the  various  infectious  diseases 
particularly  the  surgical-wound  diseases,  certain  micro-organisms  in  the 
blood  and  internal  organs,  and  we  know  that  every  infectious  disease  is  due 
to  some  specific,  plainly  distinguished  class  of  micro-organism.  These  gain 
access  to  the  body  from  without  by  means  of  the  inspired  air,  the  food,  water 
or  by  contact  with  the  surface  of  the  body,  especially  if  there  is  an  interrup- 
tion of  continuity  in  the  skin  or  mucous  membranes.  The  striking  results 
obtained  by  antisepsis  and  the  aseptic  method  of  operating  and  treating 
wounds  demonstrate  that  the  infectious-wound  diseases  are  caused  by  the 
entrance  of  micro-organisms  into  the  wound  from  without.  If  we  perform 
an  operation,  taking  every  precaution  not  to  introduce  microbes  by  our 
hands  or  instruments,  or  from  the  patient's  own  skin,  into  the  woxind,  or, 
briefly,  if  we  operate  aseptically,  as  we  have  learned  in  a  previous  chapter, 
with  everything  germ-fi-ee  and  sterile,  and  then  dress  the  wound  with  germ- 
free  (sterilised)  materials,  such  a  wound  will  invariably  heal  without  iaflam- 
mation  and  suppuration  per  primam  intentionem,  or,  in  other  words,  by 
immediate  agglutination  of  its  bordei's,  and  without  giving  rise  to  fever.  If 
there  is  a  transgression  of  the  rules  of  asepsis  or  antisepsis  in  performing  an 
operation  or  treating  a  wound,  and  if  micro-organisms  get  into  the  wound, 
inflammation  and  suppuration  and  other  wound  diseases,  accompanied  by  a 
corresponding  febrile  disturbance,  will  result.  If  an  infected  wound  is  treat- 
ed with  disinfecting  substances,  such  as  bichloride  (1  to  1,000-5,000)  or  three- 
.  per-cent.  carbolic  solutions,  the  micro-organisms  are  prevented  from  further 
development  and  the  existing  inflammation  or  suppuration  is  modified  or 
checked,  provided  it  has  not  already  become  too  far  advanced  and  no  general 
systemic  poisoning  has  taken  place.  A  further  proof  of  the  microbic  origin 
of  the  infectious  diseases  is  furnished  by  the  successful  results  of  transmis- 
sion from  animal  to  animal.  Cultures  of  a  particular  kind  of  bacteria  which 
had  caused  a  certain  infectious  disease,  were  introduced  into  the  body  of  an 
animal  and  here  produced  the  same  disease,  and  the  same  kind  of  bacteria 
could  be  isolated  from  the  diseased  tissues.  The  micro-organisms  damage  the 
human  organism  in  a  double  manner — viz.,  by  the  formation  of  the  poison- 
ous products  of  their  metabolism,  and  by  multiplying  very  rapidly  and  invad- 
ing new  portions  of  tissue. 

The  Diflferent  Kinds  of  Micro-organisms. — We  recognise  four  large 
classes  of  micro-organisms  :  I.  The  fungi  or  monlds.  II.  The  sprout- 
ing or  yeast  fungi  (saccharomycetes,  blastomycetes).  III.  The  fission 
fungi,  bacteria  (schizomycetes).     TV.  Mycetozoa  and  protozoa. 

I.  Fungi, — Moulds  form  the  well-known  green,  yellow,  whitish,  or  black 
skinlike  covering  found  upon  all  sorts  of  dead  organic  substances.  They 
usually  consist  of  two  functionally  distinct  parts,  the  mycelium  and  the  ger- 
minal Lypha  or  zygospore.  The  mycelium  consists  of  branching,  usually 
jointed  threads,  which  anastomose  with  one  another  and  prolifei^ate  in  the 
nutrient  substrata.  The  zygospores  spring  from  the  mycelium  and  produce 
and  carry  on  their  ends  the  seeds  or  spores  (Figs.  248  to  251).  The  latter  are 
round  or  elongated  cells  generally  having  a  dense  enveloping  membrane. 


256 


INFLAMMATION  AND  INJURIES. 


and  after  separation  from  the  zygospore  are  capable  of  forming  another  fun- 
gus with  its  zygospore.  Tlie  spores  can  retain  their  vitality  in  a  dry  state 
for  from  two  to  teji  years.  Numerous  species  of  fungi  are  distinguished  by 
the  manner  in  which  the  spores  form  upon  the  zygospores.  Occasionally  the 
spores  undergo  segmentation  by  transverse  division  of  the  terminal  cells  at 
the  exti*eniity  of  the  zygospore  (couidia).  In  other  fungi  the  terminal  cell 
develops  into  the  so-called  sporangium  or  ascus,  in  the  interior  of  which  the 
spores  fonn  by  division  of  the  plasma  (ascospores).  In  still  others  two  zygo- 
spores grow  one  within  the  other,  and  the  so-called  oospores  develop  at  the 
point  of  junction  of  the  two  spore  carriers.  The  same  fungus  will  occasion- 
ally form  its  spores  in  several  different  ways,  depending  upon  the  conditions 
in  wliicli  it  exists  (eonidia  and  ascospores). 

Conditions  Suitable  for  the  Life  of  the  Fungi— The  fungi  are  found  upon 
every  description  of  dead  substance,  and  upon  substances  which  contain  a 
relatively  small  amount  of  water  and  have  an  acid  reaction,  thus  differing 
from  the  bacteria.  For  making  pure  cultures  of  fungi,  the  best  materials 
are  boiled  potatoes,  bread  pulp,  and  gelatine,  or  the  agar  mixture  rendered 
acid  by  the  addition  of  two  to  live  per  cent,  of  tartaric  acid,  to  prevent 
bacteria  from  taking  root  along  with  the  fungi.  The  temperature  is  an 
important  matter,  some  species  thriving  best  at  +  15°  C.  (59°  F.),  and  an- 
other at  +  40°  C.  (104°  F.).  The  spores  will  only  form  when  there  is  plenty 
of  air.  oxygen  being  essential,  and  consequently  most  of  the  fungi  will 
not  multiply  in  the  interior  of  animal  tissues  nor  in  blood ;  they  ordinarily 
exist  only  upon  such  portions  of  the  body  as  are  freely  exposed  to  the  atmos- 
pheric air. 

Penicillium. — The  commonest  fungus  is  the  Penicillium  glaucum  (Fig. 
248).     It  grows  in  distilled  water  and  many  kinds  of  medicine,  best  at  a  tern- 


Fig.  248. — Penicillium  glaucum.     x  180. 


Fig.  249. —  Oidium  Inctis  grown  on  milk 
and  then  cultivated  in  bouillon,     x  250. 


perature  of  from  15°  to  20°  C.  (59°  to  68°  F.).  while  at  .88°  C.  (101°  F.)  it 
gradually  dies.  The  mycelium  has  a  flocculent.  white  appearance,  turning 
green  after  the  formation  of  the  spores.  The  latter  do  not  grow  when  intro- 
duced into  warm-blooded  animals  by  injection  into  the  blood  or  by  inhala- 
tion, and  they  may  remain  for  weeks  in  the  liver  and  spleen. 


§  59.] 


MICRO-ORGANISMS. 


25Y 


Oidium. — There  are  numerous  species  of  the  oidiuni  which  flourish  partly 
upon  a  dead  substratum  and  partly  (like  mildew)  upon  living  plants.  They 
are  regularly  present  upon  sour  milk.  Mycelium  and  spores  ai'e  white. 
They  thrive  best  at  a  temperature  between  19°  to  30°  C  (50°  to  86°  F.).    They 


Fig.  250. — Mucor  raceTnosus.  x  175.  Grown 
on  moist  rye  bread.  The  outer  capsule  of 
the  sporangium  has  been  broken  by  pres- 
sure against  the  cover-glass,  and  spores  are 
seen  coming  out. 


^ 


Fig.  251. — Aspergilhis  fumigatus.,  a  patho- 
genic fungus  cultivated  on  moistened 
bread,      x  250. 


consist  partly  of  cylindrical  bodies  lying  together  and  forming  an  angle  with 
each  other,  and  partly  of  long  branching  and  segmented  threads.  Many  of 
the  cells  contain  small  and  large  round  bodies  (Fig.  249).  Fungi  of  the  oidi- 
um class  are  found  in  favus,  pityriasis  versicolor,  and  herpes  tonsurans. 

Monilia. — The  nionilia  is  distinguished  from  the  oidium  by  its  zygospore, 
which  takes  a  bushy-shaped,  branching  form  as  it  springs  from  the  myce- 
lium. Cultures  of  monilia  conidia  if  inoculated  into  the  skin  of  the  dove's 
neck  will  cause  thrush  (see  also  page  260). 

Mucor. — There  are  many  species  of  mucor,  some  of  which  thrive  best  at 
a  temperature  of  37°  C.  (98.6°  F.),  and  cause  death  in  rabbits  when  their 
spores  are  injected  into  the  blood-vessels  in  large  amounts.  There  are  then 
found  in  the  internal  organs,  particularly  the  kidney,  a  great  number  of 
small  fungi  which  do  not  fructify.  They  are  chiefly  found  in  man,  in  the 
external  auditory  meatus.     The  spores  are  developed  in  sporangia  (Fig.  250). 

Aspergilli. — They  generally  germinate  like  the  conidia,  less  frequently 
having  ascospores.  The  Aspergillus  glaucus  is  greenish  yellow,  is  harmless 
as  regards  warm-blooded  animals,  and  is  generally  found  ii:i  damp  walls, 
preserved  fruits,  etc.  The  Asjyergilliis  fumigatus,  flavescens,  and  suhfuscus 
are  pathogenic,  and  the  most  favourable  temperature  for  their  growth  is  about 
37°  C.  (98.6°  F.).  The  injection  of  large  numbers  of  the  spores  will  kill  rab- 
bits, numerous  foci  of  the  fungus  being  found  in  the  heart,  liver,  and  kid- 
neys. Spores  of  Asjoergillus  fumigatus  exist  chiefly  in  the  air-passages  of 
birds.  In  man,  colonies  of  this  species  of  aspergillus  have  been  observed  in 
the  bronchi,  lungs,  external  auditory  meatus,  upon  the  cornea,  in  the  facial 
cavities,  etc. 

Pathological  Importance  of  the  Fungi  for  Man.— The  pathological  bear- 
ing of  the  fungi  upon  man,  as  ascertained  by  experimental  and  clinical 
18 


258  INFLAMMATION  AND  INJURIES. 

observations,  is  briefly  as  follows :  It  is  well  known  that  the  fungi  occasion- 
ally find  lodgment  in  the  epithelium  of  the  skin  and  mucous  membranes, 
and  in  the  former  situation  give  rise  to  favus,  herpes  tonsui-ans,  pityi'iasis 
versicolor  and  other  skin  diseases,  and  in  the  latter  to  thrush.  Later  investi- 
gations have  led  most  authorities  to  believe  that  the  exciting  cause  of  thrush 
is  a  yeast  fungus  (see  pages  259  and  200  and  Fig.  253).  Zenker  found  in  the 
brain  of  a  child  affected  with  thrush  multiple  abscesses  with  sprouting  spores 
of  the  thrush  fungus  in  their  centres.  The  question  as  to  whether  fungi  can 
grow  in  the  living  tissues  of  warm-blooded  animals  has  been  answered  in 
the  affirmative  by  both  Grohe  and  Grawitz.  This  is  particularly  true  if  the 
fungi  have  first  become  adapted  by  "  accommodative  cviltivation ''  to  the 
heterogeneous  conditions  of  alkaline  blood  at  a  temperature  of  39°  C.  (Gra- 
witz). Further  experiments  made  by  Koch  and  others  have  demonstrated 
that  there  are  pathogenic  fungi  which  are  capable  of  development  in  the 
tissues  of  warm-blooded  animals  without  having  undergone  any  previous 
pai'ticular  kind  of  cultivation,  while  the  non-pathogenic  fungi  never  possess 
this  power  even  though  they  have  first  been  subjected  to  cultivation.  The  non- 
pathogenic fungi  include  the  PenicilUum  glaucum,  the  Aspergillus  glau- 
cus  and  niger,  the  Mucor  muceclo,  and  stolonifer.  The  species  which  are 
certainly  pathogenic  include  :  1.  The  Aspergillus  fumigatus  (Fig.  251),  dis- 
tinguished from  the  Aspergillus  glaucits  by  its  very  small  size  and  that  of  its 
spores,  its  dirty  green  colour,  the  manner  of  its  growth,  its  jjoor  development 
at  ordinary  temperatures,  and  the  very  i^apid  growth  manifested  in  tempera- 
tures equal  to  blood  heat.  The  Aspergillus  fumigatus  is  present  in  bread, 
and  is  readily  cultivated  on  dough  kept  at  a  temperature  of  39°  to  40°  C.  (102.2° 
to  104°  F.),  as  a  dark-green  fungous  covering.  2.  The  Aspergillus  flavescens 
is  similar  to  i\\Q  Aspergillus  fumigatus, sai(\.  is  characterised  by  its  yellowish- 
green  colour.  3.  The  Mucor  rhizoj)Ocliformis  is  distinguished  from  the  non- 
pathogenic mucor  {Rhizopus)  by  the  greyish-brown  colour  of  its  mycelium, 
the  large  size  of  its  individual  parts,  its  small,  round,  colourless  spores,  and 
by  the  egg-.shaped  columella  dilated  at  its  top.  4.  The  Mucor  corymhifer  is 
known  by  the  snow-white  colour  of  its  mycelium  and  its  characteristic  form. 
Internal  fungous  diseases  arising  spontaneously  in,  for  instance,  the 
lungs  and  intestinal  tract,  are  seldom  seen  in  man,  as  the  pathogenic  fungi 
(of  the  aspergillus  and  mucor  varieties)  will  only  thrive  at  a  high  tempera- 
ture, and  consequently  are  not  very  plentiful  in  the  air,  water,  or  alimentary 
substances.  Furthermore,  the  fungi  are  only  pathogenic  when  they  exist  in 
great  numbers,  while  the  system  is  capable  of  overcoming  a  few  of  them 
without  itself  suffering  harm  (Grawitz),  and  their  increase  by  means  of 
spores  does  not  take  place  in  living  tissue.  Fungous  diseases  are  most  easily 
excited  by  intravenous  injection  of  the  organisms.  Lichtheim's  mucor  in- 
jections proved  fatal  in  rabbits  in  every  case,  while  dogs  were  not  affected 
at  all.  Morse,  Kaufmann,  and  Schulz  caused  animals  to  inhale  and  swallow 
large  amounts  of  pathogenic  fungi  without  producing  any  ill  effect;  Licht- 
heim  noted  only  a  scanty  and  stunted  vegetation  in  the  lungs  after  inhalation. 
In  man  there  is  occasionally  observed  a  pneumomycosis  aspergillina  {Asper- 
gillus fumigatus)  and  a  pneumomycosis  mucorina,  secondary  to  already 
existing  pulmonary  disease.  There  is  also  a  keratomycosis  aspergillina,  a 
corneal  lesion,  and  an  aspergillus  mycosis  of  the  facial  cavities  and  the  ex- 


59.] 


MICRO-ORGANISMS. 


259 


ternal  auditory  meatus  (oto-  or  m yriiigo-mycosis  aspergillina),  produced  by  the 
Asjyergillus  fumigatus,  flavescens,  and  nigrescens.  According  to  Carter, 
the  Madura  foot,  a  disease  like  elephantiasis,  endemic  in  India,  and  charac- 
terised by  the  formation  of  warty  lumps,  suppurating  in  their  interior  and 
terminating  in  death  after  about  a  year,  is  caused  by  a  fungus,  the  Chionyphe 
Carteri,  related  to  the  Mucor  stolonifer ;  but  other  investigatoi^s  have  dis- 
puted this.  As  a  general  thing,  man  may  be  said  to  be  immune  to  the  patho- 
genic fungi  hitherto  identified ;  but  under  conditions  not  yet  understood 
these  fungi  may  take  on  a  fatal  activity,  as  exemplified  by  the  above-men- 
tioned case  of  Zenker's,  and  a  recently  described  and  interesting  case  of  Pal- 
tauf,  in  which  a  man  died  in  coma  after  what  appeared  to  be  an  enteritis 
and  peritonitis.  In  the  brain,  lungs,  and  intestine  were  found  inflammatory 
foci,  or  abscesses,  containing  mycelia  of  the  mucor  variety  {Mucor  corymbi- 
fer).  It  is  by  no  means  impossible  that  still  other  new  forms  of  fungous  dis- 
ease may  be  found  to  have  their  existence  in  man.  All  the  facts  which  are 
known  as  regards  the  pathogenic  fungi  are  of  great  surgical  interest.  The 
fungi  play  a  very  important  part  in  the  production  of  diseases  in  plants  and 
low  orders  of  animal  life,  such  as  the  grape  disease,  the  potato  disease,  the 
"  rot "  of  grain,  the  muscardine  disease  of  silkworms,  and  various  diseases  in 
insects,  etc. 

II.  The  Yeast  Fungi  {Blastomycetes).—The  yeast  fungi  (Fig.  252)  are 
round,  oval  cells  of  difFerent  sizes,  varying  from  two  to  fifteen  micromillime- 
tres  in  diameter,  having  a  thin  enveloping  membrane  and  granular  proto- 
plasm, in  which  there  are  frequently 
vacuoles  (Fig.  252).  They  multiply 
by  budding  or  putting  forth  daugh- 
ter cells,  which  finally  become  sepa- 
rated from  the  mother  cells  by  a  par- 
tition, and  either  remain  in  contact 
with  their  parent  cell  for  a  consider- 


FiG.  252. — Yeast  fungus.  Saccharoviyces 
cerevisiw.  Vacuoles  are  present  in 
some  of  the  larger  cells. 


Fig.  253. — Saccharomyces  albicans.     Thrush 
fungus.     X  250.     (Heim.) 


able  time,  forming  more  or  less  long  chains,  or  they  become  entirely  sepa- 
rated. Many,  though  not  all,  of  the  yeast  fungi  produce  in  solutions  of  sugar 
alcoholic  fermentation,  changing  grape  sugar  into  carbonic  acid  and  alcohol. 
The  true  yeast  fungi  which  cause  fermentation  (saccharomycetes)  must  be 
distinguished  from  the  other  fungi  of  the  same  class.  The  mycelia  of  the 
typical  mould  fungus — for  instance,  the  mucor  species — can  form  chains  and 
can  cause  alcoholic  fermentation  in  a  solution  of  sugar.  Macroscopically  the 
yeast  plant  forms  a  white  cloudy  sediment  in  a  fermenting  fluid,  or  a  white 
scum  over  the  surface  of  alcoholic  fluids  which  are  spoiling.     In  solid  nutri- 


260  INFLAMMATION  AND   INJURIES. 

live  media  (gelatine)  the  yeast  fungus  makes  spores  by  developing  free  cells 
within  the  enlarged  mother  cell  (ascospores).  Beer-wort  and  decoctions  of 
malt  or  prunes,  to  which  sugar  is  afterwards  added,  form  the  best  culture 
media,  but  they  must  be  mixed  with  one  per  cent,  of  tartaric  acid  to  keep 
out  the  bacteria. 

The  pathological  interest  of  the  yeast  fungi  is  limited  ;  they  occasionally 
give  rise  to  fermentation  in  the  stomach.  Most  authorities  hold  that  thrush, 
a  common  inflammation  of  the  mucous  membrane  of  the  mouth  and  throat 
is  caused  by  a  yeast  fungus  (Saccharomyces  albicans,  see  Fig.  253) ;  other 
authorities  have  considered  this  a  mould  fungus.  A  disease  occurring  late 
in  the  autumn  is  caused  by  a  yeast  fungus  {Empusa  mnscxe).  More  serious 
diseases  have  of  Tate  been  found  to  be  due  to  certain  yeast  fungi.  Busse 
described  a  fatal  infection  in  a  man  of  thirty-one,  caused  by  a  yeast  fungus, 
which  ran  a  course  similar  to  a  chronic  pyajmia.  At  first  an  abscess  devel- 
oped in  the  left  tibia,  then  ulcers  in  the  skin  of  the  face,  and  further  diseased 
foci  in  the  right  ulna  and  the  sixth  rib  on  the  left  side.  Death  occurred 
thirteen  months  from  the  beginning  of  the  disease.  The  autopsy  showed 
extensive  destructive  changes  in  both  kidneys,  both  lungs,  and  spleen,  and 
small  nodules  on  the  pleura  resembling  tubercles.  All  the  foci  contained  a 
white  yeast  fungus  in  great  amounts  ;  it  was  present  within  the  cells.  Pure 
cultures  of  the  fungus  cells  proved  to  be  pathogenic  for  dogs  and  mice.  The 
latter  died  in  from  four  to  ten  days  after  subcutaneous  injections  of  fluid 

cultures.     This  disease,  described  by 

;/.;•  '•.•?,'w»       *■■•      ":   .•*"■•■  Bus.se,  resembles  actinomycosis  most 

.•*,,•;.        "i^ft**  )    "**"'    /  closely.     Buschke  has  also  made  ob- 

••••*  "/'iT'  '-..      •••''*  servations  regarding  the  pathogenic 

^  ^  c  nature  of  mould  fungi  in  man.     Ac- 

iSnJ^Ss.  X5-1  cording  to  him.  the  fungi  are  situated 

'J^Wil       ^^*K^i>5  ^^^^       Vv«V.     ^^^  P^'**  ^"  '^^®  superficial  epithelium 

"iv.^v"       ''•-S'-^^i'  ^^^^M       *\***       of  the  skin  and  mucous  membrane. 


and  give  rise  here  to  ulcers,  catarrhal 
inflammation,  etc.,  and  in  part  pene- 
trate into  the  interior  of  the  animal 
Fig.  254. — Different  varieties  of  cocci :  a.  Small-      „_,j    V,„»>i„,-.    K^^i^     ^„      •    ~      -ii 

erandlar.rereocci;6,diplococci;o,ehaiu  ^^d.  ^uman  body,  causing  either  a 
coccus  (streptococcus) ;  flf,«,  clusters  of  cocci  variety  of  septica?mia  or  onlv  local 
in  the  tonn  of  a  bunch  of  grapes  (staph  vlo-      „!,„„"„    ■      ^u     i-  tj.  •      ^       -i-i 

cocci) ;  /,  sarcina  (packet  coccus) ;  ff,  Mi-  c^ianges  m  the  tissues.  It  IS  possible 
crococcus  tetragon  US.  that  in  the  future  many  of  the  dis- 

eases of  the  skin,  mucous  membranes, 
and  serous  surfaces  will  be  found  to  be  due  to  the  yeast  fungi.  Maffucci  and 
Sirleo  have  also  come  to  the  conclusion  that  there  are  pathogenic  and  yeast 
fungi  which  under  certain  conditions  may  give  rise  to  septica?mia.  suppura- 
tion, or  cJironic  inflammatory  new-formations  of  the  type  of  the  granulation 
tumours. 

III.  The  Bacteria  {Schizomycetes). — The  l)acteria  (from  ro  l3aKT'f]ptov, 
a  small  rod,  from  the  rod  shape  which  many  of  them  have)  are  very 
small,  simple  cells  of  a  low  order  of  vegetable  life  i^elated  to  the  lower 
orders  of  algre.  They  are  divided  into  several  distinct  classes,  accord- 
ing to  their  shape  and  the  effects  which  they  produce.     ]S"evertheless, 


§59.] 


MICRO-ORGANISMS. 


261 


under  altered  conditions  in  their  life  the  bacteria  of  one  class  change 
their  shape  and  function  to  a  greater  or  less  degree.     There  are  chiefly 

1.  The  mi- 


to  be  distinguished 


®  & 

(g)C5) 


© 


® 


® 


® 


crococci. 
spirilla. 


2.  The  bacilli.    3.  The 


@® 


^ 


<^ 


^ 


® 


Fig.  255. — Tubercle  bacilli  from  the  sputum 
of  a  thirty-eight-year-old  phthisical  pa- 
tient. The  sputum  was  dried  on  a  cover- 
glass  and  stained  with  fuchsin  and  methy- 
lene violet.     X  700. 


/\ 


Fig.  256. — Blood  from  a  mouse  with  anthrax, 
dried  on  the  cover-glass  and  stained  with 
methyl  violet.  Ked  blood-corpuscles  and 
anthra.x  bacilli,     x  700. 


1.  The  Sjyherical  Bacterium  {Micrococcus  m^  Coccus). — The  micro- 
cocci are  small,  round,  or  oval  cells,  which  by  division  or  fission  always 
produce  in  turn  the  same  round  cells.  The  micrococci  exist  either  as 
isolated  spherules  (Fig.  254,  «),  or  they  remain  in  pairs  after  dividing 
(diplococcus,  Fig.  25-4,  J),  or  the  spherules  cling  together  in  chains 
(streptococcus,  Fig.  254,  c).  In 
other  instances  they  form  ir- 
regular groups  (staphylococ- 
cus, Fig.  254,  6?,  e).  Large 
groups  or  colonies  bound  to- 
gether by  some  sticky  mate- 
rial such  as  mucus  are  called 
zoogloa.  Sometimes  the  mi- 
crococci develop  in  groups  of 
four  (merismopsedia,  merista, 
Fig.  254,  g),  or  they  are  joined 
together  in  cubes  (sarcina,  Fig. 
254,  y ).  The  sarcina  is  found 
in  the  stomach  of  man,  as  Sa?'- 
cina  ventriculi.,  when  fermen- 
tation is  present. 

2.  Rod-shaped  Bacteria  {the  Bacillus).— In  all  bacilli  the  longi- 
tudinal diameter  exceeds  the  transverse,  and  their  size  varies  very 
greatly  (Figs.  255,  256,  257).     The  bacilli  divide  transversely,  and,  like 


m^ 


257.— Anthrax  thread.s  from  the  blood  of  a 
mouse.  Culture  in  bouillon  at  24°  C,  ten  hours 
old  :  a.  threads  made  up  of  single  bacilli,    x  700. 


262 


INFLAMMATION  AND  INJURIES. 


Fig 


258. — SpirochoiUe  Ober- 
tneieri.     x  700. 


Fig.  2.59. — Group  of 
f'ibrio  serpens. 
X  650(Flugge). 


the  cocci  or  the  streptococci,  they  form  longer  or  shorter  threads  by 
remaining  attached  to  one  another  after  division  (leptothrix).  These 
threads,  in  contrast  to  the  mould  fungi,  never  become  branched,  though 
several  threads  lying  next  each  other  may  give 
the  appeai'ance  of  branches.  Particularly  the 
r^       ^^^    '~^  anthrax  bacilli  (Fig.  257)  and 

vliy      ,^,     -  - '  the  bacilli  of  malignant  oede- 

ma  have   the  form  of   long 
threads.    Many  bacilli  j^ossess 
an  enlargement  at  their  cen- 
tre or  end,  and  such  spindle- 
shaped  or  tadpole-formed  rods 
are  known  as  clastridia. 
3.   The   Spiral-shaped  Rod   Bacillus   {Sjnrillum). — The   spirilla 
(Fig,  258)  have  the  appearance  of  spirally  twisted  threads  or  fragments 
of   cork-screws.      The   bacterium   which   has   the   twist   but  slightly 
marked  is  known  as  a  vibrio  (Fig.  259j. 

Under  each  of  the  separate  classes  of  bacteria  there  are  many  varie- 
ties and  species  which  are  of  great  importance  from  a  diagnostic  stand- 
point. Thus  there  are  small  or  large,  oval  or  lancet-shaped  cocci,  also 
slender  and  broad  bacilli,  etc.  Within  one  sj^ecies  differences  occur 
depending  upon  the  conditions  of  nourishment  or  age. 

The  Structure  and  Reproduction  of  Bacteria.  — The  bacteria,  like  other 

vegetable  cells,  consist  of  an  inner  portion  surrounded  by  an  envelojD- 

^--  ing  membrane.     Their  interior  is  made 

.     ^  *•  ,  0  up  of   albuminoid  matter,  fats,  salts, 

/    -  .^         tj  ■  -i,  and  water,  while  the  enveloping  raem- 

'  \-     '       -^  *  't:h         brane    is    probably   allied    to   one   of 

\     '^    '      *    '.  the  cellulose  bodies  belonging  to  the 


hydrocarbon  compounds.  C.  Frankel 
and  others  consider  it  doubtful  whether 
or  not  a  nucleus  exists  within  the  pro- 
toplasmic contents  of  these  cells. 

The  bacteria  are  often  surrounded 
by  a  gelatinous  enveloping  substance, 
which  facilitates  the  formation  of  the 
above-mentioned  bands.  It  can  in 
some  cases  be  made  visible  by  the  usual 

staining  materials,  but  in  others  a  special  treatment  is  necessary  with 

iodine. 

Movements  of  Bacteria. — Many  bacilli  and  spirilla  are  capable  of 

active  movement,  and  of  moving  from  one  spot  to  another.     The  micro- 


V 


^% 


1i' 


f':' 


Fig.  2fi0. — Diplococcus  of  Frankel  (cap- 
.sule  coccus).  Pus  taken  from  a  case 
of  empyema,     x  1,000. 


59.] 


MICRO-ORGANISMS. 


263 


Fig.  261. — Bacteria  with  flagella  (diagrammatic). 


cocci  do  not  possess  the  power  of  locomotion,  but  are  seen  to  have  only 
a  tremulous  molecular  '•  Brownian  "  movement ;  but  Loffler  and  Men- 
doza  have  recently  discov- 
ered two  species  of  micro- 
cocci which  do  have  the 
power  of  motion.  The  loco- 
motion of  the  bacilli  and 
spirilla  which  are  capable  of 
motion  is  brought  about  by 
peculiar  organs  called  cilia 
or  flagella.  Loffler,  by  means 
of  a  special  method  of  stain- 
ing, has  demonstrated  these 
fiagella  in  a  number  of  the 
more  important  pathogenic  bacteria.  The  different  forms  of  fiagella 
are  shown  in  Fig.  261.  They  are  found  either  at  one  end  only  or  at 
both  ends,  and  are  single,  double,  or  in  the  form  of  bunches.  Many 
bacteria,  such  as  the  typhoid  bacillus  and  the  bacillus  of  malignant 
oedema,  have  their  entire  periphery  covered  with  fine  cilia,  causing 
them  to  resemble  a  spider  or  a  centipede  (Figs.  261  and  262). 

In  place  of  Loffler's  stain  for  fiagella,  Bunge  recommends  the  following 
mixture,  which  acquires  its  full  efficiency  only  after  long  exposure  to  the 

air :  Three  parts  concentrated 
solution  of  tannin,  one  part 
five-per-cent.  liquor  ferri  chlo- 
ridi,  to  which  is  added  one 
cubic  centimetre  of  concen- 
trated aqueous  solution  of  f uch- 
M  -i,         ^      sin  to  ten  cubic  centimetres  of 


the  mixture. 

Reproduction  of  Bacteria. 

— Some  bacteria  multiply  by 
direct  division  or  fission  ;  the 
cells  become  somewhat  in- 
creased in  length,  and  form 
two  separate  and  distinct  in- 
dividuals, or  they  remain  ad- 
herent to   each  other  after 
division  (diplococcus,  strep- 
tococcus, vibrio).     The  mul- 
tiplying power  of  the  fission  fungi  is  enormous.    If,  as  Fliigge  says,  the 
average  length  of  time  required  for  fission  to  occur  is  one  hour,  there 
will  be  formed  from  each  bacterium  within  twenty-four  hours  about 


Fig.  262. — Typlioicl  bacilli  with  numerous  fine  fiagella. 


V 


^' 


264  INFLAMMATION  AND  INJURIES. 

sixteen  million  new  ones.    Manj  bacteria,  such  as  the  Bacillus  snhtilisy 
the  Bacillus  anthracis^  and  the  bacillus  of  malignant  cedema,  propagate 
themselves  by  the  formation  of  spores,  which  is  an 
^^*"*««i^  ^  actual  fructitication  in  the  interior  of  the  cells — that 

i   ^         is,  by  the  formation  of  a  strongly  refracting,  shining 
body,  which  is  set  free  by  the  atrophy  of  the  re- 
^        mainder  of  the  cells  (Fig.  204).    Each  cell  forms  only 
^         a  single  spore.     If  the  spores  find  lodgment  in  a  nu- 
tritive medium,  they  sooner  or  later  germinate,  and 
each  spore  will  develop  into  a  cell  similar  to  the 
Fig.  263.— Foraiation     mother  Cell  from  wliicli  the  spore  originated.     Spore 

of  endospores  (dia-       -.  .  ,  ,  ,  ,     .  .  '  .  , 

grainmatic).  lormatiou  lias    been   observed  m  various  species  of 

bacilli  and  in  some  of  the  spirilla,  but  hitherto  in 
none  of  the  micrococci.  The  bacteria  undergo  spore  formation  for  the 
purpose  of  propagating  the  species,  particularly  when  at  the  height  of 
their  development  and  when  the  conditions  governing  their  nutrition 
and  growth  are  at  the  best.  By  subjecting  the  protoplasm  of  the  bac- 
teria to  certain  injurious  influences  their  power  of  spore  formation 
can  be  temporarily  or  permanently  arrested  (Lehmann,  Behring,  etc. ). 
From  a  pathological  standpoint  the  capability  which  the  spores  possess 
of  withstanding  noxious  influences,  such  as  dryness,  heat,  cold,  or 
chemical  substances,  is  of  great  importance.  The  spores  of  many  bac- 
teria can  retain  their  vitahty  unimpaired  for  as  much  as  a  year  when 

kept  in  a  dry  condition,  or  even 
T^«*.^  \      B*^-  in  absolute  alcohol.     A  dry  heat 

'^*^^^l  \\\  ^        of   1^^°    C-   ^284°    F.)  destroys 


\     y«>»»*"''"^*'*'«X"'i'^i^Sl&>*?       \  \  _«"^ 


^^V'-^^'"*'"*'       their  power  of  reproduction  with 
"^S-^^  f\  certainty  only  after  many  hours, 


/ 


■ms 


'*A 


7      •        /  ''^ 


^ 


Fig.  264. — Formation  of  spores  in  anthrax  bacilli  (Koch) :  «,  From  the  spleen  of  a  mouse  after 
twenty-four  hours'  culture,  x  050;  J,  germination  of  the  spores,  x  650;  c,  specimen  h  ojag- 
nified  1,650  times. 

and  they  can  withstand  boiling  for  several  minutes.  Globig  had  to 
subject  the  spores  of  the  potato  bacillus  to  the  action  of  steam  for 
more  than  four  hours  before  they  died.  This  great  power  of  resist- 
ance which  spores  possess  is  probably  due  to  the  remarkably  tough 


§59.] 


MICRO-ORGANISMS. 


265 


Fig.  265. — Spore  formation  (b)  in 
bacilli  of  malignant  cedema. 
Agar  culture.  «',  bacillus  with 
flagella.      x  1,000. 


character  of  their  enveloping  membrane,,  and  perhaps  also  to  the 
chemical  composition  of  their  interior.  The  spores  of  the  different 
kinds  of  bacteria  vary  very  much  in  their  capabilities  of  resisting  nox- 
ious conditions. 

Arthrospores. — Besides  the  endospores,  a 

or  those  which  are  formed  in  the  interior 
of  the  cells,  there  are  also  arthrospores 
(Fig.  266).  They  owe  their  existence  to 
the  fact  that  certain  segments  of  a  chain, 
string,  or  cluster  of  bacteria  have  more 
vitality  than  the  others ;  entire  cells  sepa- 
rate themselves  from  their  surroundings 
and  form  new  chains  or  groups,  and  thus 
propagate  their  species  after  the  other  bac- 
teria have  died.  The  arthrospores  have 
no  other  typical  means  of  recognition,  and 
they  are  not  particularly  resistant  to  un- 
favourable influences. 

The  Occurrence  of  Bacteria  and  the  Conditions  Suitable  for  their  Life. — 
Bacteria  are  found  everywhere.  The  air,  earth,  water,  and  the  things 
which  they  contain,  our  clothing,  our  food,  skin,  etc.,  support  a  vast 
number  of  these  invisible  living  beings  or  plants,  and  only  the  normal 
organs,  the  blood  and  the  lymph  in  the  healthy  body  of  man  and  ani- 
mals, are  free  from  them.  Bacteria  do  not  originate  by  spontaneous 
generation,  or  generatio  OBquivoca — i.  e.,  by  springing  from  molecules 
of  another  kind — but  they  grow  only  from  spores  of  their  own  species 
(Pasteur  and  others).  The  above-described  spores  are 
the  principal  means  for  the  preservation  of  the  various 
kinds  of  bacteria. 

From  the  fact  that  bacteria  are  found  almost  every- 
where, it  follows  that  they  require  but  little  for  their 
development ;  the  smallest  amount  of  organic  material 
is  capable  of  supporting  them.  They  require  chiefly 
nitrogen  and  compounds  of  carbon.  The  amount  of 
nutritive  matter  which  the  different  species  need  varies 
very  much,  but  in  general  they  require,  besides  inor- 
ganic material,  food  which  contains  nitrogen  (albumen), 
or  is  free  from  nitrogen  (sugar,  glycerine).  It  is  very  important  that 
the  nutritive  medium  should  be  alkaline,  or  at  least  neutral  in  reaction, 
as  bacteria,  with  a  few  exceptions,  do  not  grow  in  an  acid  medium. 
The  bacteria  which  grow  exclusively  in  dead  organic  material  are  called 
the  obligate  saprophytic,  while  the  obligate  parasitic  bacteria  are  those 


Fig.  266.— Arthro- 
spores (cliagram- 
matic). 


266  INFLAMMATION  AND  INJURIES. 

which  only  grow  in  the  living  body  of  a  warm-hlooded  animal.  But 
there  are  a  vast  number  of  bacteria  which  are  saprophytic  (living  upon 
dead  organic  matter),  and  exist  as  parasites,  the  so-called  facultative 
parasitic  or  facultative  saprojihytic  fungi. 

Adaptation  of  Bacteria  to  Unsuitable  Nutritive  Media. — Bacteria 
have  the  power  of  adapting  themselves  gradually  to  media  which  are 
unfavourable  to  their  development,  and  are  thus  able  to  accommodate 
themselves  even  to  antiseptic  solutions,  like  bichloride,  when  they  are 
allowed  to  become  gradually  accustomed  to  it.  Trambusti  succeeded, 
in  the  case  of  Friedlander's  j^neumococcus  and  other  bacteria  (the  an- 
thrax bacillus  and  the  Sta^jJiylococcus  pyogenes  aureus^  etc.),  in  inci-eas- 
ing  the  concentration  of  the  bichloride  of  mercury  contained  in  the 
nutritive  bouillon  from  1  to  40,000  up  to  1  to  2,000  without  interfer- 
ing with  their  development.  But  if,  on  the  other  hand,  these  microbes 
were  placed  immediately  in  a  bichloride  bouillon  mixture  of  a  strength 
of  1  part  bichloride  to  15,000  of  bouillon,  their  development  ceased 
immediately. 

Influence  of  Oxygen. — Oxygen  plays  a  very  important  part  in  the 
life  of  bacteria.  Many  species  will  grow  only  in  the  presence  of  free 
oxygen  {obligate  aerobic  bacteria),  while  the  obligate  anaerobic  bacteria 
will  only  do  so  when  free  oxygen  is  absent  from  their  nutritive  medium. 
Other  bacteria — and  they  include  the  majority  of  the  pathogenic  bac- 
teria— are  facultative  aerobic  and  facultative  anaerobic ;  i.  e.,  their 
growth  is  not  dependent  on  the  presence  of  oxygen,  though  the  facul- 
tative aerobic  flourish  heiiev  ivith  oxygen,  and  the  anaerobic  without  it. 

Influence  of  Temperature. — Temperature  has  an  important  influence 
upon  them.  A  certain  amount  of  warmth  is,  of  course,  necessary  for 
the  development  of  bacteria  as  well  as  for  any  kind  of  life,  and  each 
species  has  its  own  temperature — that  is,  there  is  a  range  of  tempera- 
ture for  each  species  which  is  best  adapted  for  the  gro^vth  of  that  spe- 
cies. The  saprophytes  are  best  suited  l:)y  the  ordinary  temperature  of 
a  room  (20°  to  25°  0.-68°  to  77°  F.),  the  parasites  by  blood  heat  (35° 
to  40°  0. — 95°  to  104°  F.),  while  other  classes  are  capal^le  of  growing 
at  temperatures  close  above  the  freezing  point,  and  even  below  it. 
When  the  temperature  is  abnormally  high  or  low  the  bacteria  l)ecome 
benumbed  by  the  heat  or  cold,  and  if  the  temperature  rises  or  falls  still 
more  they  perish.  It  is  well  known  that  the  spores  have  a  remark- 
able power  of  resisting  extremes  of  temperature.  The  limits  of  tem- 
perature compatible  with  the  development  of  most  of  them  lie  between 
40°  and  50°  0.  (104°  to  122°  F.) ;  of  others,  between  60°  and  70°  0. 
(150°  to  168°  F.).  The  pus  cocci,  when  in  a  dry  state,  can  retain  their 
vitality  for  a  longtime  at  a  temperature  of  80°  0.  (186°  F.).     Globig 


§  59.]  MICRO-ORGANISMS.  267 

and  Miquel  have  discovered  bacteria  which  can  still  grow  and  multiply 
at  a  temperature  ranging  between  60°  and  T0°  C.  (150°  to  168°  F.). 

Influence  of  Light. — Exposure  to  sunlight  has  a  deleterious  efEect 
upon  certain  bacteria,  such  as  the  tubercle  and  anthrax  bacilli,  which 
die  comparatively  quickly  under  the  direct  action  of  the  sun. 

Influence  of  the  Galvanic  Current. — The  bactericidal  action  of  the 
galvanic  current  is  due,  according  to  Charrin  and  Burci,  to  electrolysis 
in  its  surrounding  fluid ;  nascent  iodine  has  a  particularly  strong 
action.  Cultures  of  different  bacteria  (staphylococci,  streptococci, 
anthrax  spores,  etc.)  in  a  one-  to  four-per-cent.  solution  of  potassium 
iodide  if  subjected  to  a  constant  current  of  two  to  ten  milliamperes 
are  killed  at  the  positive  pole,  when  iodine  is  set  free,  in  five  to  thirty 
minutes,  but  not  at  the  negative  pole.  In  the  tissues  the  constant  cur- 
rent seems  to  have  no  particular  effect  upon  bacteria. 

The  Products  of  the  Life  and  Metabolism  of  the  Bacteria. — By  means 
of  their  vital  activity  the  bacteria  generate  certain  products  of  metab- 
olism, of  which  some  exert  a  restraining  influence  upon  the  growth 
of  the  bacteria  ;  such  products  are  carbonic  acid,  lactic  acid,  acetic  acid, 
etc. ;  upon  other  species  of  bacteria  the  increasing  alkalinity  of  the  nutri- 
tive medium  acts  unfavourably.  Many  bacteria  generate  ferii.ents  or 
soluble  organic  bodies  which  readily  change  such  complicated  insoluble 
compounds  as  albumen  or  starch  into  soluble  substances,  acting  in  the 
same  way  as  the  pepsin  or  ptyalin  does  in  animal  organisms.  In  many 
bacteria  there  is  a  peptonising  ferment  which  will  liquefy  gelatine,  and 
this  is  a  matter  of  much  importance  for  diagnostic  purposes.  In  fact, 
the  various  species  of  bacteria  have  been  divided  into  the  general  classes 
of  those  which  liquefy  and  do  not  liquefy  gelatine. 

Ptomaines  and  Toxines. — Bacteria  are,  furthermore,  the  cause  of  fer- 
mentation and  decomposition,  and  in  this  connection  it  was  first  dis- 
covered that  bacteria  form  poisonous  products  of  metabolism  called 
ptomaines  and  toxines.  It  has  long  been  known  that  certain  poison- 
ous products  are  developed  during  decomposition.  In  1863  Panum 
isolated  a  substance  which  he  called  the  "  poison  of  decomposition,"  and 
Bergmann  and  Schmiedberg  a  crystalline  body  which  they  called  sep- 
sine.  At  present  we  know  that  the  cause  of  many  infectious  diseases 
lies  in  the  action  of  those  poisons  which  are  produced  by  the  micro- 
organisms. Ptomaines  are  nitrogenous  substances  which  are  formed 
from  the  constituents  of  the  animal  organisms  by  the  metabolism  of 
the  bacteria.  As  they  are  derivatives  of  ammonia  they  have  errone- 
ously been  called  alkaloids.  Ptomaines  that  have  a  poisonous  action 
are  called  toxines.  A  large  number  of  these  ptomaines  have  been  iso- 
lated in  a  pure  state. 


268  INFLAMMATION  AND  INJURIES. 

Nencki  was  the  tirst  to  isolate  collidin  and  determine  its  formula. 
Many  other  investigators  have  since  devoted  themselves  to  the  study 
of  ptomaines  and  toxines.  Brieger  has  isolated  several  ptomaines  and 
toxines  from  cultures  of  bacteria — e.  g.,  peptutoxine,  neurine,  ueuri- 
dine,  cadaverine,  muscarine,  phlogosin,  choline,  etc.  He  also  obtained 
very  poisonous  toxines  from  cultures  of  typhoid  and  tetanus  bacilli 
(typliotoxine,  tetaniue,  tetanotoxine).  Their  very  poisonous  character 
was  demonstrated  by  the  inoculation  of  animals.  Some  toxines  have  a 
similar  action  to  morphine,  curare,  or  atropine.  Peptotoxine  causes 
death  in  the  animals  experimented  upon  with  symptoms  of  paralysis  ; 
and  neurine,  according  to  Bi-ieger,  acts  like  muscarine,  causing  salivation, 
contraction  of  the  pupils,  disturbances  of  respiration  and  circulation, 
and  clonic  spasms.  This  explains  the  general  systemic  poisoning  of 
various  kinds  due  to  bacterial  infection  of  wounds,  and  in  part  the 
cases  of  poisoning  caused  by  ingestion  of  decomposing  food  with  the 
ptomaines  it  contains  (meat,  sausage,  milk,  and  cheese  poisoning). 
The  toxines  can  be  separated  from  the  bacteria  by  filtration  through 
porcelain,  and  then,  by  injecting  the  toxines  beneath  the  skin  of  ani- 
mals, it  is  possible  to  study  their  poisonous  manifestations.  If  cultures 
of  bacteria  are  subjected  to  a  temperature  of  60°  C,  the  micro-organ- 
isms will  perish,  and  the  poisonous  effects  of  many  of  the  ptomaines 
can  be  studied  ;  but  others  are  destroyed  by  a  high  temperature.  Tox- 
ines, which  belong  to  different  groups  of  chemical  bodies,  are  in  some 
instances  resistant  to  heat,  and  in  others  non-resistant.  Buchner  called 
those  substances  within  the  bacterial  cells  which  resist  heat,  pi'oteins. 
Those  substances  which  do  not  resist  heat,  and  are  found  in  the  culture 
fluid,  are  called  by  Brieger  and  Frankel  toxalbumins,  on  account  of 
their  supposed  albuminous  nature.  Hankine  calls  them  albumoses, 
but  the  general  term  toxines  is  better.  The  nature  and  composition  of 
the  nutritive  medium  plays  an  important  part  in  the  formation  of  the 
toxines  produced  by  any  particular  kind  of  bacteria — i.  e.,  the  same 
bacteria  do  not  under  all  circumstances  produce  the  same  toxines. 
Even  harmless  bacteria,  like  the  Micrococcus  jyrodigiosus^  may,  when 
combined  with  some  second  species  also  non-pathogenic,  become  dan- 
gerous to  the  animal  economy.  The  specific  poisons  of  many  bacteria 
— for  example,  the  tubercle  bacilli — are  not  found  in  the  nutritive 
medium,  but  chiefly  in  the  bodies  of  the  bacteria  themselves,  so 
that  tuberculosis  can  be  excited  by  dead  tubercle  bacilli  (K.  Koch, 
Prudden,  Hodenpyl,  etc.).  Buchner  showed  even  earlier  that  the 
above-mentioned  proteins  which  are  intimately  connected  with  the 
bacterial  cells  cause  inflammation  and  have  a  toxic  action.  Buchner, 
Lange,  and  F.  Roemer  pointed  out  that  these  poisonous  bacterial  pro- 


§59.] 


MICRO-ORGANISMS. 


269 


I 


teins  and  certain  toxines  have  a  great  power  of  attraction  for  the  leuco- 
cytes (chemotaxis),  and  after  intravenous  injection  cause  an  increase  in 
the  number  of  the  leucocytes  (leucocytosis).  The  properties  possessed 
by  these  bacterial  proteins  of 


causing  inflammation,  and  par- 
ticularly fever  (general  toxic 
action),  have  become  more  and 
more  firmly  estabhshed  by  the 
latest  investigations.  (Anti- 
toxines,  see  page  277.) 

Pigment  Formation. — Many 
bacteria  form  colouring  mat- 
ter (Figs.  267-269)  of  many 
diflEerent  shades,  such  as  white, 
black,  red,  blue,  yellow,  green, 
and  brown,  giving  to  the  cul- 
ture, and  often  to  a  great  part 
of  the  nutritive  medium,  a 
characteristic  tinge.     The  pus 


^/-?: 


Fig.    267. — Staphylococcus  pyogenes 
citreus,  potato  culture. 


Fig.  268.— Streak  culture       Fig.  269.— Streak  culture 
of  Bacillus  prodigio-  oi  Bacillus pyocyaneus 

sus  on  asrar.  on  asrar. 


is  sometimes  coloured  by  bacteria.  The  pigment  bacteria,  in  all  proba- 
bility, possess  a  chromogenic  body,  which  when  exposed  to  the  influ- 
ence of  oxygen  changes  to  a  colouring  matter. 

Phosphorescence. — Many  bacteria  are  phosphorescent — i.  e.,  they  are 
luminous  in  the  dark  (Fischer). 

Products  of  the  Bacteria— Different  Effects  of  the  Products.— Arloing  and 
Courmont  distinguish  three  principal  classes  of  the  products  of  the  patho- 
genic bacteria  :  1.  The  substances  precipitable  by  alcohol  (diastases,  by  acidi- 
fied alcohol  (toxalburaens).  by  Millon's  reagent  (peptones).  Diastases  and  tox- 
albumens  are  capable  of  dialysis  only  to  a  slight  extent.     2.  The  substances 


270  INFLAMMATION   AND   INJURIES. 

which  ai'e  sohible  in  alcohol  and  ether  and  can  be  precipitated  by  acetate  of 
lead  and  bichloride  of  mercury  are  dialysable  and  are  but  slightly  altered 
by  heat  (ptomaines,  alkaloids).  3.  The  volatile  substances,  coloured  com- 
pounds of  carbon,  etc.  Some  of  the  products  have  toxic,  some  predisposing, 
and  some  immunif^'ing  properties,  and  they  have  all  been  isolated  from  vari- 
ous species  of  bacteria  (Behring,  Friinkel,  Rovet,  etc.). 

The  marasmus  accompanying  acute  and  chronic  diseases  due  to  bacterial 
infection  is  caused  by  the  i^roducts  of  the  metabolism  of  the  bacteria,  as  Man- 
netti  has  proved  in  the  case  of  the  metabolic  products  of  the  Staphylococcus 
pyogenes  aureus  and  alhus. 

The  Limitations  to  the  Growth  of  Bacteria;  their  Death. — Various 
influences  place  restraints  upon  the  growth  of  the  bacteria,  such  as  too 
low  or  too  high  temperatures,  absence  of  water,  the  addition  of  certain 
chemical  substances  or  bacterial  poisons  to  their  nutritive  medium,  etc. 

If  noxious  influences  are  not  permitted  to  act  too  intensely  upon 
the  bacteria  the  latter  become  weakened,  and  this  weakening  process 
can  be  kept  up  through  several  generations,  causing  the  pathogenic 
species  to  lose  their  virulence  partially  or  completely.  Cultures  of 
bacteria  which  have  been  thus  weakened  have  often  been  employed 
for  inoculating  purposes  as  a  prophylactic  measure  against  infectious 
diseases. 

If  the  above-mentioned  noxious  influences  are  permitted  to  act  too 
intensely  or  too  long  the  bacteria  will  finally  die.  It  is  possible  to  kill 
bacteria  by  a  great  number  of  chemical  substances,  the  chief  of  which 
are  our  commonly  used  antiseptics,  bichloride  of  mercury  and  carbolic 
acid,  provided  they  are  employed  in  sufficiently  concentrated  solutions. 
Bacteria  may  also  be  destroyed  by  insufiicient  nourishment,  by  depri- 
vation of  water,  by  exposure  to  the  direct  rays  of  the  sun,  or  by 
other  antagonistic  bacteria  or  the  products  of  their  metabolism  (acids, 
alkalies),  and  especially  by  abnormally  low  or  high  temperatures,  rang- 
ing from  50°  to  80°  C.  (122°  to  176°  F.)  and  higher.  As  we  have  said 
before,  low  temperatures  are  less  injurious,  as  a  general  thing,  than 
abnormally  high  temperatures.  Many  of  those  bacteria  which  do  not 
form  spores,  and  the  majority  of  the  kinds  which  do,  are  capable  of 
retaining  their  vitality  in  ice.  The  spores  are  also  very  resistant  to 
high  grades  of  temperature,  ranging  between  50°  and  80°  C.  In  gen- 
eral they  are  killed  only  at  a  temperature  of  100°  C,  some  of  them 
needing  to  be  subjected  to  it  from  two  to  ten  minutes,  and  others  sev- 
eral hours.  Budding,  sprouting  spores  are  more  rapidly  killed  than 
those  which  have  not  budded.  The  most  effective  manner  of  destroy- 
ing bacteria  is  by  subjecting  them  to  boiling  water  or  hot  steam.  Dry 
heat,  at  a  temperature  of  140°  to  160°  C.  (284°  to  320°  F.),  requires 
three  hours  to  kill  bacteria,  while  boiling  water  or  steam  only  requires 


§  59.]  MICRO-ORGANISMS.  271 

from  five  to  ten  minutes.     According  to  Tassinari,  tobacco  smoke  has 
a  decided  bactericidal  power. 

Tests  and  Comparisons  of  the  Germicidal  Substances. — The  efficacy  of  a 
germicide  is  tested  by  inoculating  the  bacterial  matter  previously  subjected 
to  its  influence  upon  living  animals  and  observing  whether  or  not  infection 
follows,  or  fresh  moist  or  dried  colonies  may  be  placed  upon  glass  slides,  silk 
threads,  grains  of  sand,  etc.,  and  thus  brought  into  contact  for  a  certain 
length  of  time  with  the  germicide  that  is  to  be  tested.  The  colonies  thus 
treated  are  then  placed  in  some  nutritive  medium,  such  as  gelatine  or  bou- 
illon, and  kept  at  a  temperature  of  35°  C.  (77°  F.).  If  chemical  substances 
are  to  be  tested,  the  glass  slides  or  threads,  etc.,  must  first  be  washed  in  ster- 
ilised distilled  water  to  prevent  them  from  carrying  any  of  the  poison  into 
the  nutritive  gelatine,  and  consequently  restraining  the  growth  of  the  bac- 
teria. After  the  cultures  have  been  kept  at  the  proper  temperature  for  sev- 
eral days,  and  have  shown  no  development  of  colonies  of  bacteria,  it  may  be 
inferred  that  the  previously  existing  organisms  have  been  killed  by  the  sub- 
stance in  question. 

Ordinary  Methods  of  Studying  Bacteria.— The  methods  of  bacteriological 
investigation  consist  principally  in  the  study  of  stained  preparations  under 
the  microscope,  in  the  formation  of  cultures,  and  in  the  inoculation  of  ani- 
mals with  pure  cultures  of  the  different  bacteria.  The  microscopical  part  of 
the  investigation  of  bacteria  has  been  greatly  advanced  by  Robert  Koch, 
who  showed  the  necessity  of  homogeneous  immersion  and  the  proper  way 
of  using  Abbe's  condenser  or  illuminating  apparatus.  The  basic  aniline 
dyes  are  the  best  materials  for  staining  both  the  bacteina  and  the  cell  nuclei. 
We  employ  aqueous  solutions  of  gentian  violet,  fuchsin,  and  especially 
methylene  blue — e.  g.,  thirty  centimetres  of  a  concentrated  alcoholic  solution 
of  methylene  blue,  one  hundred  centimetres  of  water,  and  twenty  drops  of 
one-per-cent.  caustic  potash,  or  a  solution  containing  fifteen  drops  of  carbol 
fuchsin,  twenty  grammes  of  distilled  water,  and  eight  drops  of  concentrated 
alcoholic  solution  of  methylene  blue.  If  it  is  desired  to  make  a  preparation 
rapidly  from  a  fluid  containing  bacteria,  a  drop  of  the  liquid  is  evaporated 
upon  a  cover-glass.  The  residue  is  fixed  by  passing  the  cover-glass  three 
times  through  the  flame  of  a  Bunsen  burner,  and  then  placing  it  for  a  few 
minutes  in  one  of  the  above-mentioned  staining  solutions — methylene  blue, 
for  example.  In  case  the  above  alcoholic  carbol-fuchsin-methylene-blue 
solution  is  used,  eight  to  ten  seconds  is  sufficient.  The  excess  of  colouring 
matter  is  then  washed  from  the  cover-glass  with  distilled  water,  the  specimen 
placed  upon  a  slide  and  examined  in  the  bright  light  provided  by  the  Abbe 
condenser,  with  or  without  a  blender.  The  importance  of  the  Abbe  con- 
denser lies  in  the  fact  that  it  brings  into  prominence  the  coloured  portions 
of  the  stained  preparation,  especially  the  nuclei  and  the  bacteria.  When 
unstained  objects  are  to  be  examined  the  use  of  the  condenser  is  to  be 
restricted — i.  e.,  a  narrow  blender  is  to  be  used,  and  less  light  allowed  to  fall 
upon  the  slide.  In  examining  with  the  microscope  fluids  containiiag  bac- 
teria, it  is  a  good  plan  to  use  hollowed-out  slides.  For  the  I'ecent  methods 
of  staining  bacteria  I  must  refer  the  reader  to  the  text-books  of  Frankel, 
Hueppe,  Gunther,  Eisenberg,  and  others. 


272  INFLAMMATION  AND  INJURIES. 

Culture  Methods— The  Vaxious  Kinds  of  Culture  Media.— By  artificial 
cultures  of  bacteria,  and  their  subsequent  inoculation  upon  animals,  our 
knowledge  of  the  effects  produced  by  bacteria  has  been  very  much  advanced. 
Bacteria  ai'e  cultivated  partly  in  liquid  and  partly  in  solid  nutritive  media. 
The  vessels  for  conducting  the  experiments  are  exj^osed  to  dry  heat  at  a  tem- 
perature of  160°  C,  in  a  sterilising  apparatus,  for  from  one  to  two  hours, 
while  the  nutritive  media  are  sterilised  in  advance  in  a  Papin's  digester, 
or  by  steam,  in  order  to  kill  the  bacteria  which  may  already  be  existing 
in  them. 

The  fluid  nutritive  media  (infusion  of  meat,  infusion  of  hay,  milk,  urine, 
blood  serum,  etc.)  are  inferior  in  every  respect  to  the  translucent  solid  media 
(gelatine,  agar-agar).  In  the  liquid  media  it  is  possible  to  watch  the  growth 
and  multiplication  of  bacteria  by  means  of  "cultures  in  banging  drops." 
"With  the  aid  of  a  sterilised  platinum  wire  hook  a  drop  of  the  sterilised  nutri- 
tive liquid  is  placed  upon  a  cover-glass  which  has  just  been  heated;  to  the 
drop  is  then  added  a  very  small  amount  of  the  culture.  A  concave  glass 
slide  is  sterilised  by  heat,  vaseline  placed  around  the  concavity,  and  the 
cover-glass  laid  upon  the  vaseline  circle,  with  the  drop  of  nutritive  liquid 
dipping  into  the  concavity.  The  solid  nutritive  media  (gelatine,  agai'-agar) 
become  fluid  at  temperatures  between  25°  and  30°  C.  and  35°  and  40°  C, 
respectively,  but  solidify  rapidly  on  cooling.  If  bacteria  ai'e  planted  in  the 
most  commonly  used  nutritive  gelatine  (bouillon,  eight  per  cent,  gelatine, 
one  per  cent,  peptone,  one-half  per  cent,  common  salt),  which  has  been 
heated  to  a  temperatui*e  of  30°  C.  in  a  test  tube,  and  so  liquefied,  and  if  the 
well-mixed  fluid  is  then  poured  upon  sterilised  glass  plates  or  saucers,  the 
bacteria  will  grow  in  the  rapidly  hardening  gelatine,  and  after  the  lapse  of 
one  or  two  days  will  form  visible  separate  cultui'es.  The  microscope  shows 
that  each  colony  is  made  up  of  individuals  of  the  same  species.  To  prevent 
the  colonies  from  growing  too  thickly,  it  is  best  to  dilute  the  gelatine  first 
infected,  and  to  pour  the  diluted  liquid  upon  a  larger  number  of  glass  plates, 
a  portion  of  the  nutritive  medium  in  the  first  glass  being  emptied  into  a 
second,  to  which  gelatine  is  then  added,  and  this  last  fluid  is  then  mixed 
with  more  gelatine  in  still  a  third  glass.  All  the  mixtures  are  then  poured 
into  a  little  shallow  glass  dish.  The  agar  mixture,  which  remains  solid  up 
to  a  temperature  of  38°  C.  is  employed  for  bacteria  requiring  a  temperature 
higher  than  25°  C.  It  is  thus  possible  to  make  cultures  of  any  desired  spe- 
cies of  bacteria  in  a  solid  medium.  The  cut  surfaces  of  slices  of  a  boiled 
potato  are  also  much  used  as  a  solid  nutritive  medium,  and  distinct  colonies 
can  be  made  to  grow  upon  them  by  spreading  out  over  the  surface  of  the 
potato  thus  prepared  a  single  drop  of  liquid  containing  three  or  four  species 
of  bacteria.  Under  proper  conditions  every  bacterium  will  then  develop  into 
a  separate  colony.  For  some  bacteria  (pus  cocci,  diphtheria  bacilli,  tubercle 
bacilli.  FrankeFs  ^  "leumococcus)  human  saliva  and  sputum  furnish  a  good 
nutritive  medium  (Schmidt,  Grawitz). 

The  diff"erent  species  of  bacteria  require  particular  kinds  of  nutritive 
media — blood  serum,  for  instance— while  other  species  must  have  media 
which  do  not  contain  oxygen.  The  latter  requirement  is  obtained  by  a  thick 
layer  of  gelatine  or  agar,  or  by  supplanting  the  air  in  the  culture  vessel  by 
hydrogen  gas,  or  by  the  addition  of  reducing  substances  (one  to  two  per 


§  59.] 


MICRO-ORGANISMS. 


2T3 


?^^?#^ 


cent,  dextrose,  formate  of  sodium,  pyrocatechiii,  etc.).     A  number  of  known 
bacteria  have  as  yet  eluded  all  attempts  at  cultivation. 

The  behaviour  of  the  cultures  in  the  nutritive  media,  such  as  gelatine  or 
agar,  can  now  be  watched  very  exactly.  Some  species,  for  example,  form 
dry  white  masses,  others  white  slimy  drops,  and 
still  other  colonies  liquefy  the  gelatine,  or  de- 
velop into  colonies  having  a  bright  red,  yellow, 
or  green  colour,  etc. 

If  a  cover-glass  placed  upon  the  gelatine 
plate  is  pressed  lightly  on  the  colonies  growing 
upon  the  surface,  and  then  lifted  off,  a  portion  of 
the  colony  will  cling  to  the  glass.  This  cover- 
glass  preparation  is  then  passed  three  times 
slowly  through  the  Bunsen  flame,  treated  with 
a  drop  of  fuchsin  or  gentian  violet,  washed  with 
water,  and  examined  under  the  microscope. 

Needle-point  or  Stab  Cultures.— The  needle- 
point cultures  are  especially  important  (Fig. 
270),  and  are  made  in  the  following  manner : 
A  platinum  wii'e  is  brought  into  contact  with 
some  particular  colony  of  bacteria,  and  then 
plunged  into  nutritive  gelatine  contained  in  a 
glass  test-tube.  In  the  region  of  the  puncture 
the  characteristic  culture  will  develop. 

Linear  or  Streak  Cultures.— When  a  linear 
culture  (Fig.  271)  is  made  the  gelatine  is  allowed 
to  harden,  so  that  its  surface  forms  a  plane 
obliquely  directed  towards  the  sides  of  the  test- 
tube,  and  over  this  surface  is  lightly  drawn  the 
platinum  wire  which  carries  the  bacteria. 

Of  course  care  must  be  taken  in  both  the 
needle-point  and  linear  cultivations  that  only 
the  particular  species  of  bacteria  to  be  investi- 
gated is  introduced. 

These  few  general  remarks  on  the  methods  of  investigation  pursued  in 
bacteriology  will  suffice  for  our  purpose.  More  detailed  descriptions  can  be 
liad  by  reference  to  the  text-books  of  C.  Frankel,  Fliigge,  Hueppe,  and  others. 
In  the  description  of  the  different  bacteria  of  surgical  importance  we  shall 
return  to  the  discussion  of  cei'tain  other  questions. 

The  Action  of  Pathogenic  Bacteria— Methods  of  Transmission,  and 
Experimental  Inoculation  of  Animals.— The  boundaries  between  the 
noxious,  disease-producing  or  pathogenic  bacteria  and  the  non-patho- 
genic are  not  very  sharply  defined.  Even  non-pathogenic  bacteria 
can  under  certain  conditions,  as  before  remarked,  do  a  great  deal  of 
Tiarm,  while,  on  the  other  hand,  even  virulently  pathogenic  micro- 
organisms may  in  various  ways,  such  as  by  peculiar  methods  of  culti- 
vation, be  rendered  weak  or  entirely  inert  (see  page  275). 
19 


Fig.  270.— Stab 
or  puncture 
culture. 


Fig.  271. — Linear 
culture. 


27^:  INFLAMMATION  AND   INJURIES. 

How  do  the  patliogenic  bacteria  act ?  The  pathogenic  bacteria 
produce  their  noxious  etifeets,  in  the  first  place,  by  forming  specific, 
extremely  poisonous  products  of  metabolism  (toxiues,  see  page  267) 
which  damage  the  animal  organism  in  a  definite  way.  Other  species 
of  bacteria  become  dangerous  to  the  animal  economy  on  account  of 
their  great  numbers.  They  increase  with  great  i-apidity  and  spread 
throughout  the  body,  as  is  the  case  with  the  anthrax  bacilli,  which  in  a 
purely  mechanical  way  produce  ver}-  serious  changes  in  the  different 
organs,  and  prove  fatal  by  consuming  the  nutritive  matter,  albu- 
minous substances,  and  oxygen,  which  are  necessary  to  the  life  of  the 
organism. 

Toxic  and  Infectious  Bacteria. — The  first  class  of  bacteria  are  the 
toxic,  the  second  are  the  infectious.  The  toxic  bacteria  form  their 
poisons  outside  of  the  body  only,  and  are  incapable  of  developing  inside 
the  living  body.  If  they  gain  access  in  sufficient  numbers  to  poison 
the  body  they  are  carried  to  all  the  different  organs  by  the  circulating 
blood,  and  can  be  perhaps  demonstrated  in  them  here  and  there ;  but 
their  presence  is  of  secondary  importance,  as  the  main  thing  is  the  poi- 
son which  they  have  produced,  upon  the  kind  and  amount  of  which, 
the  disease  depends.  The  animal  organism  is  poisoned  by  toxic  bac- 
teria both  from  the  use  of  cultures  that  contain  the  bacteria  and  those 
that  are  germ-free.  The  infectious  bacteria,  on  the  other  hand,  pos- 
sess the  power  of  multiplying  within  the  organism  in  which  they  find 
lodgment,  and  of  spreading  themselves  through  it;  and  even  though 
very  few  in  number  when  first  introduced,  they  can  increase  with 
incredible  rapidity,  flooding,  as  it  were,  all  the  organs  of  the  body. 
The  anthrax  bacillus  is  a  good  example  of  this  variety  (see  §  77). 
Schimmelbusch  and  Ricker  were  able  to  demonstrate  anthrax  bacilli  in 
the  internal  organs  (heart,  lungs,  liver,  spleen,  kidneys)  in  half  an 
hour,  and  the  Bacillus  jyyocyaneus  in  five  minutes  after  the  infection 
of  fresh  wounds.  Hand  in  hand  with  the  increase  in  the  number  of 
micro-organisms  goes  an  increased  formation  of  the  poisonous  products 
of  their  metabohsra,  leading  to  intoxication  (poisoning)  of  the  body. 
The  original  infection  may  be  produced  by  the  entrance  into  the  body 
of  an  exceedingly  small  number  of  microbes.  The  same  species  of 
bacteria  may  prove  mfectious  for  one  kind  of  animal  but  not  for 
another ;  but  by  feeding  an  animal  in  a  certain  way,  or  by  subjecting 
a  particular  species  of  bacteria  to  proper  cultivation,  the  animal  may 
be  I'endered  susceptible  or  not  to  the  particular  species  of  bacteria. 
The  glanders  bacillus  has  an  exceedingly  virulent  effect  upon  field- 
mice,  but  white  mice  are  not  affected  by  it.  If,  however,  the  white 
mice  are  fed  upon  phoridzin  until  they  become  diabetic,  they  change 


§  59.]  MICRO-ORGANISMS.  275 

and  are  then  susceptible  to  this  bacillus.  According  to  Arloing's 
statement,  the  bacilli  of  malignant  oedema  become  infectious  for  such 
animals  as  are  ordinarily  not  affected  bj  them  if  the  animals,  previous 
to  their  inoculation,  are  soaked  in  a  twenty- per-cent.  solution  of  lactic 
acid,  or  if  their  tissues  are  first  treated  with  pyrogallic  or  carbolic 
acids,  or  bichloride  of  mercuiy. 

Attenuation  of  the  Virulence  of  Bacteria. — It  has  hitherto  been 
impossible  to  effect  a  permanent  increase  in  the  virulence  of  the  bac- 
teria, or  to  change  the  toxic  bacteria  into  the  infectious  class,  or  vice 
versa  /  but,  on  the  other  hand,  a  lasting  attenuation  and  even  a  total 
destruction  of  their  virulence  is  possible,  as  in  the  case  of  the  bacilli 
of  chicken  cholera  and  anthrax,  the  pneumococci,  etc.  (Pasteur,  Tous- 
saint).  This  attenuation  of  the  virulence  of  pathogenic  bacteria  may 
be  brought  about  in  a  natural  as  well  as  in  an  artificial  way.  The 
natural  attenuation  will  take  place,  as  demonstrated  by  Fliigge's  experi- 
ments, in  such  infectious  bacteria  as  are  compelled  to  grow  for  a  long 
time  under  conditions  differing  from  those  governing  their  ordinary 
existence  and  development,  such  conditions  being  represented  by  arti- 
ficial nutritive  media  or  atmospheric  surroundings  to  which  they  are 
not  accustomed.  By  causing  certain  bacteria  to  accommodate  them- 
selves to  growth  upon  dead  substances — that  is,  giving  them  a  sapro- 
phytic method  of  life — their  capability  of  developing  in  the  animal 
organism  is  lost.  A  similar  loss  of  specifi-C  action  can  be  produced  in 
saprophytic  bacteria  by  cultivating  them  under  altered  conditions 
(Hueppe  and  others).  The  virulence  of  bacteria  can  also  be  modified, 
and  even  permanently  abolished,  by  subjecting  them  to  various  influ- 
ences which  are  injurious  to  them.  The  poisonous  character  of  an- 
thrax bacilli  has  thus  been  rendered  weaker  or  destroyed  by  cultivation 
of  the  organisms  in  antiseptic  or  disinfecting  nutritive  media,  such  as 
bouillon  containing  bichromate  of  potassium  (1  to  2,000-5,000),  or 
anthrax  blood  containing  one  per  cent,  of  carbolic  acid,  or  by  cultiva- 
tion under  a  pressure  of  eight  atmospheres,  or  by  exposure  of  the 
culture  to  the  direct  rays  of  the  sun.  Likewise,  by  breeding  a  special 
species  of  bacteria  several  times  in  animals  which  are  not  susceptible 
to  it,  the  virulence  of  this  species  can  be  diminished.  The  surest  and 
most  usual  way  of  "  attenuating  their  virus  "  is  the  cultivation  of  bac- 
teria in  high  temperatures ;  and  the  lower  the  temperature  that  one 
uses  for  bringing  this  about  the  longer  the  process  of  attenuation  will 
take,  but  it  becomes  just  so  much  the  more  permanent,  so  that  the 
weakened  poisonous  character  of  the  bacteria  is  transmitted  to  their 
offspring,  and  in  this  way  it  is  possible  to  make  a  series  of  completely 
attenuated  cultures.     The  attenuated  differ,  in  all   probabihty,  from 


276  INFLAMMATION   AND   INJURIES. 

the  virulent  bacteria  in  possessing  a  degenerated  proto])lasm,  a  defect- 
ive vitality,  a  diminished  power  of  growth,  less  ability  to  withstand 
injurious  influences,  and  especially  in  having  diUerent  products  of 
metabolism.  Yiruient  anthrax  bacilli,  for  example,  form  a  greater 
amount  of  acid  than  the  attenuated  ones.  Therefore,  bacteria  which 
have  been  attenuated  or  weakened  do  not  flourish  in  the  animal  system, 
as  they  are  incapable  of  overcoming  its  natural  oppositions  or  hin- 
drances to  their  growth,  and  they  die  i-elatively  quickly  either  at  the 
point  of  infection,  or  in  the  blood,  and  especially  in  the  organs  where 
they  are  deposited  by  the  blood — viz.,  the  liver,  spleen,  and  bone 
marrow. 

Power  possessed  by  the  Animal  Organism  of  protecting  itself  against 
Bacteria. — The  healthy  animal  or  human  body  possesses  various  means 
of  protecting  itself  against  the  entrance  of  bacteria.  The  serum  of  the 
blood,  particularly  if  free  from  cellular  elements,  has  a  direct  germi- 
cidal power,  as  has  been  demonstrated  by  the  beautiful  experiments  of 
Buchner,  Niessen,  Stern,  and  others.  This  germicidal  power  of  the 
blood  is  due  to  the  formation  of  protective  substances  (antitoxines) 
which  Buchner  and  Hahn  called  alexines.  The  latter  are  dissolved 
albuminous  substances  which  are  derived,  according  to  Buchner,  from 
the  white  blood -corpuscles.  The  alexines  are  destroyed  as  soon  as 
they  come  in  contact  with  the  decomposition  products  of  the  bacteria, 
while,  on  the  other  hand,  the  bacteria  themselves  are  destroyed  by  the 
alexin-es  (Buchner  and  Hahn).  It  is  a  fight  for  life  or  death,  and  the 
stronger  wins.  The  injection  of  certain  fluids  into  the  blood — e.  g., 
nuclein,  tuberculin,  etc. — causes  a  marked  increase  in  the  number  of 
white  blood -corpuscles,  and  this  artificial  leucocytosis  probably  in- 
creases the  resisting  power  of  the  blood  against  bacteria.  The  germi- 
cidal power  of  the  blood  in  a  given  individual  appears  to  have  a 
different  intensity  at  different  times.  According  to  H.  Buchner,  it  is 
dependent  also  upon  the  proportion  of  salts  it  contains.  Fodor  says 
that  the  germicidal  power  of  the  blood  is  increased  as  its  temperature 
is  raised  and  as  it  becomes  more  alkaline  by  the  addition  of  alkaline 
substances.  At  a  temperature  of  38°  to  40°  C.  (100.4°  to  104°  F.)  the 
germicidal  action  of  the  blood  is  greatest,  but  above  40°  C.  (104°  F.)  it 
rapidly  decreases.  At  all  events,  it  is  mainly  by  chemical  processes,  if 
we  leave  out  of  consideration  the  local  anatomical  peculiarities,  that 
the  animal  organism  protects  itself  against  the  entrance  of  bacteria. 
Up  to  a  certain  point  there  is  also  a  conflict  between  the  bacterial  cells 
and  the  cells  in  the  body  of  the  animal.  According  to  Metschnikoff, 
it  is  ]3rincipally  the  white  blood-cells  which  take  np  and  devour  the 
bacteria  (Fig.  272),  and  for  this  reason  he  has  called  them  devouring 


59.] 


MIC  RO-ORGANISMS. 


2Y7 


cells — phagocytes — and  to  them  he  ascribes  the  most  important  part  in 
the  battle  of  the  system  with  the  bacteria  which  have  entered  it.  This 
phagocyte  theory  of  Metschnikoff's  has  recently  been  attacked  by 
Fliigge,  Baumgarten,  "Weigert,  and  others.  These  investigators  claim 
that,  contrary  to  Metschnikoff's  idea,  the  white  blood-corpuscles  are 
always    the    ones    that 

succumb  in  the  conflict  .,4^^  .^^ss^^^ 

with  the  bacteria  if  the 
latter  enter  the  corpus- 
cles in  a  living  con- 
dition, and  that  only 
dead  bacteria  are  carried 
away  by  the  body-cells. 
The  new  investigations 


Fig.  272. — Phagocytes  (Metschnikoff) :  a,  an  anthrax  bacillus 
about  to  enter  a  white  blood-corpuscle ;  6,  the  anthrax 
bacillus  within  the  white  blood-corpuscle  ;  c,  white  blood- 
corpuscle  with  anthrax  bacilli  which  have  become  broken 
into  pieces. 


of  Buchner  and  Hahn, 
however  (p.  276),  make 

Metschnikoff's  theory  more  easy  to  understand.  The  bacteria  are  also 
carried  away  in  the  excretions,  especially  the  bile,  urine,  fseces,  and 
sweat.  Cavazzani's  claim  that  bacteria  cannot  pass  through  the  normal 
epithelium  of  the  kidney  can  no  longer  be  maintained  since  the  latest 
investigations  of  Biede  and  Kraus.  The  latter  authorities  say  that 
only  the  salivary  and  mucous  glands  and  the  pancreas  do  not  excrete 
micro-oro;anisms  under  normal  conditions. 

Natural  or  Acc[uired  Immunity  of  Animals  and  Man  towards  Bacteria. 
— The  existence  of  immunity  in  man  or  animals  towards  this  or  that 
species  of  bacteria  is  a  matter  of  great  practical  importance.  It  is 
in  part  hereditary  and  in  part  artificially  acquired.  We  know  that, 
owing  to  Jenner's  discovery  of  the  last  century,  man  can  be  made  to 
lose  his  susceptibility  to  variola  by  means  of  the  inoculation  with  cow- 
pox  virus.  The  discoveries  of  Pasteur  are  in  harmony  with  this 
important  fact — namely,  that  by  inoculation  of  a  weakened  bacterial 
poison  the  system  is  rendered  non-susceptible  to  infection  by  the 
poison  of  such  diseases  as  hydrophobia,  anthrax,  chicken  cholera,  etc. 
Though  Koch,  Loffler,  and  others  have  demonstrated,  as  regards 
anthrax,  that  inoculation  with  the  weakened  or  attenuated  anthrax 
poison  provides  no  certain  and  absolute  protection  against  this  disease, 
yet  scientifically  and  practically  the  fact  remains  established  that  the 
animal  system  can,  under  certain  circumstances,  by  inoculation  with 
the  attenuated  bacterial  poison,  be  made  unsusceptible  to  the  most 
virulent  substances — in  other  words,  the  system  becomes  artificially 
immune.  This  immunity  is  due  probably  to  the  presence  of  certain 
antagonistic  substances  (antitoxines).     The  active  principles  of  the  sub- 


278  INFLAMMATION  AND  INJURIES. 

stances  (antitoxines)  used  in  inoculation  are  probably  chemical  bodies, 
or  the  products  of  the  metabolism  of  the  bacteria  themselves.  Numer- 
ous hypotheses  have  been  advanced  for  the  explanation  of  this  acquired 
immunity.  Pasteur,  Klebs,  and  others  hold  that  it  depends  upon  the 
fact  that  during  the  first  invasion  a  quantity  of  substances  are  con- 
sumed which  are  essential  to  the  life  of  the  bacteria  in  question 
(exhaustion  theory).  Chauveau  claimed,  on  the  contrary,  that  during 
the  first  invasion  of  the  bacteria  metabolic  products  (antitoxines)  form 
from  them,  which  remain  behind  and  make  it  impossible  for  infection 
to  occur  from  the  same  species  (retention  hypothesis).  Metschnikoif 
employs  his  phagocyte  theory  (page  277)  for  explaining  acquired  immu- 
nity. C.  Frankel  is  probably  right  in  saying  that  the  acquired  tolera- 
tion of  a  poison,  or  immunity,  is  not  a  single  process,  but  is  brought 
about  now  in  this  way  and  now  in  that.  It  is  possible  that  the  exhaus- 
tion or  retention  hypothesis,  or  Metschnikoff's  cell  theory,  or  the 
chemical  action  of  the  blood  and  tissue  fiuid,  all  play  an  important 
part.  The  chief  fact  to  emphasise  here  is  that  the  human  organism, 
both  under  normal  conditions  and  in  the  course  of  infectious  diseases, 
possesses  a  powerful  means  of  protection  against  the  invasion  and 
action  of  bacteria.  The  specific  protective  substances  or  antitoxines 
are  formed  during  the  course  of  the  different  infectious  diseases  in  the 
poisoned  cells  of  certain  organs  and  are  given  over  by  them  to  the 
blood  (Ehrlich,  Wassermann,  Wernicke,  PfeifEer,  and  others).  Buch- 
ner  claims  that  the  antitoxines  are  formed  from  the  substance  of 
specific  bacterial  cells. 

Great  interest  attaches  to  the  experiments  of  Wooldridge,  Kitasato, 
and  Behring  upon  the  artificial  production  of  immunity  towards  an- 
thrax, tetanus,  and  diphtheria.  Wooldridge  discovered  that  solutions 
of  fibrinogen,  after  having  served  as  media  for  the  cultivation  of  an- 
thrax, made  an  animal  immune  to  infection  from  anthrax  ;  but,  on  the 
other  hand,  he  obtained  this  immunity  by  producing  a  slight  chemical 
alteration  in  the  fibrinogen,  without  making  use  of  the  anthrax  bacilli. 
Behring  and  Kitasato  made  rabbits  immune  towards  tetanus  by  means 
of  trichloride  of  iodine.  Behring  rendered  animals  unsusceptible  to 
diphtheria  by  (1)  employing  cultures  which  were  sterilised  or  had  been 
treated  with  trichloride  of  iodine ;  (2)  by  the  subcutaneous  and  intra- 
abdominal injection  of  the  pleuritic  exudate  which  frequently  develops 
in  animals  which  have  diphtheria ;  and  (3)  by  the  subcutaneous  injec- 
tion of  the  trichloride  of  iodine  very  soon  after  the  diphtheritic  infec- 
tion. The  capability  of  animals  for  resisting  diphtheria  was  rendered 
greater  by  the  use  of  hydrogen  peroxide.  The  blood  of  such  immune 
animals  possesses  the  power  of  destroying  the  poison  of  the  disease, 


§  59.]  MICRO-ORGANISMS.  279 

and  consequently  their  serum  has  been  used  for  subcutaneous  injection 
in  cases  of  diphtheria  with  good  results.  The  latest  experiences  with 
the  antitoxic  serum  of  diphtheria  show  that  the  mortality  of  the  cases 
treated  with  the  serum  has  become  much  less.  The  serum  acts  the 
more  quickly  the  earlier  it  is  used  in  the  disease. 

The  antitoxic  method  of  treatment  has  also  been  used  in  the  case 
of  malignant  tumours  (see  Tumours).  The  tendency  at  present  is  to 
develop  this  mode  of  treatment  more  and  more.  Certain  medicinal 
substances  of  vegetable  origin  also  possess  immunising  properties — e.g., 
extract  of  curare  is  a  preventive  and  curative  measure  against  strych- 
nine-tetanus (Laborde). 

Acquired  immunity  has  a  very  close  relationship  with  the  recovery 
from  infectious  diseases.  The  blood  or  serum  of  animals  which  possess 
a  natural  immunity  from  certain  diseases  will  probably  be  used  more 
and  more  in  the  treatment  of  those  diseases  in  man.  Efforts  are  being 
made  to  isolate  or,  in  other  words,  to  produce  in  a  pure  state,  the  anti- 
toxines  from  the  blood  and  milk  of  animals  made  artificially  immune. 
This  is  particularly  desirable,  for  the  reason  that  after  injections  of  the 
serum — e.  g.,  of  diphtheria — undesirable  complications  and  after-effectr 
are  observed  which  can  be  ascribed  to  the  animal  serum  alone,  Iv 
may  perhaps  become  possible  to  obtain  the  antitoxines — e.  g.,  of  diph- 
theria, tuberculosis,  etc.,  in  the  form  of  a  chemical  substance  with  a 
definitive  dosage,  which  can  be  obtained  at  the  druggist's.  Brieger  and 
Houx  obtained  from  ten  cubic  centimetres  of  diphtheria  or  tetanus 
serum  about  one  tenth  of  a  gramme  of  an  easily  soluble  powder  which 
contained  a  definite  amount  of  the  antitoxine. 

The  antagonism  that  exists  between  many  bacteria  probably  plays 
an  important  part  in  the  recovery  from  infectious  diseases.  The  Bacil- 
lus Jluoreseens  jputidus  (Fliigge)  is,  for  example,  a  marked  antagonist 
to  pus  cocci,  the  pneumonia  bacillus,  and  the  typhoid  bacillus,  so  that 
implantation  of  this  bacillus  in  gelatine  renders  the  cultivation  of  pus 
cocci,  typhoid  bacilli,  and  pneumonia  bacilli  impossible  (Garre).  Paw- 
lowsky  and  Bouchard  were  able  to  save  from  certain  death  rabbits 
which  had  been  inoculated  with  virulent  anthrax  bacilli,  by  bringing 
into  the  circulation  before  or  after  infection  large  quantities  of  ery- 
sipelas cocci.  Micrococcus  prodigiosus,  or  the  bacilli  of  greenish  blue 
pus.  In  other  cases  a  certain  affinity  is  observed  between  different  kinds 
of  bacteria— i.  e.,  one  species  of  bacteria  will  flourish  only  after  the 
nutritive  soil  has  been  properly  prepared  by  another  kind  of  bacteria 
(so-called  symbiosis  of  bacteria).  In  this  way  weakened  bacteria  which 
are  in  a  quiescent  condition  in  the  organism  can  reach  a  high  degree 
of  virulence  by  the  invasion  of  another  species  of  bacteria  (Babes). 


280  INFLAMMATION   AND  INJURIES. 

Method  of  Experimental  Transmission  of  Bacteria  from  Animal  to 
Animal. — Under  tJie  beading  of  pathogenic  bacteria  wbicb  have  a 
epecitic  importance,  we  class  those  which  are  capable  of  demonsti'ation 
in  all  cases  of  any  particular  disease,  and  in  no  other  disease,  and  are 
present  in  such  numbers  and  have  such  a  distribution  in  the  tissues  that 
they  readily  account  for  all  the  symptoms  of  this  particular  disease. 
The  certainty  of  the  specific  character  of  a  particular  species  of  bacte- 
ria is  established  by  its  examination  under  the  microscope,  artificial 
cultivation,  and  inoculation.  If  an  animal  dies  from  a  bacterial  dis- 
ease, the  post-mortem  examination  is  conducted  with  the  most  rigorous 
asepsis,  to  prevent  the  blood  and  organs  of  the  animal  from  becoming 
contaminated  with  any  other  bacteria.  The  skin  is  washed  in  a  one- 
tenth-per-cent.  solution  of  bichloride  of  mercury,  and  the  instruments 
are  sterilised  by  passing  them  through  the  flame  of  a  spirit  lamp. 
After  the  skin  of  the  animal  has  been  sufliciently  removed,  the  abdomi- 
nal and  thoracic  cavities  are  opened  with  sterilised  instruments  which 
have  not  before  been  used,  so  that  no  bacteria  shall  be  introduced. 
Then  the  organs  are  examined  in  the  following  order :  spleen,  liver, 
kidneys,  heart,  and  lungs.  Small  portions  of  the  blood  and  spleen, 
liver  and  lungs  are  placed  in  nutritive  fluids,  and  after  the  latter  have 
been  poured  upon  culture  plates  in  the  usual  diluted  condition  before 
described,  it  will  be  possible  to  determine  whether  bacteria  are  pi*esent 
and  of  what  species  they  are.  Parasitic  bacteria  which  will  only  grow 
at  body  temperatures  are  cultivated  on  agar  plates  kept  in  a  culture 
oven.  The  colonies  which  develop  upon  the  plates  are  then  examined, 
and  it  is  determined  whether  there  are  one  or  more  species  present,  and 
which  is  the  most  numerous.  Then  follow  the  inoculation  experiments 
of  the  pure  cultures  upon  animals,  such  as  mice,  guinea-pigs,  rabbits, 
monkeys,  pigeons,  and  dogs,  for  the  purpose  of  exciting  a  disease  sim- 
ilar in  all  respects  to  the  primary  one.  The  inoculation  is  done  by 
simple  subcutaneous  puncture,  by  making  an  incision  and  inserting  the 
culture  beneath  the  skin,  by  placing  it  in  the  anterior  chamber  of  the 
eye,  by  injecting  it  into  the  blood-vessels  or  into  the  peritoneal  or  ab- 
dominal cavities,  by  incorporating  the  culture  in  the  food,  or  introduc- 
ing it  with  the  oesophageal  bougie,  or  by  permitting  it  to  be  inhaled, 
as  Buchner  did,  by  mixing  the  culture  with  sterilised  water  or  bouillon, 
and  then  scattering  this  by  means  of  a  spray  apparatus  as  a  fine  mist 
containing  the  bacteria. 

Intra-uterine  Transmission  of  Micro-organisms  from  the  Mother  to  the 
Foetus. — The  possibility  of  the  transmission  of  micro-organisms  from  the 
mother  to  the  foetus  is  of  great  pathological  interest.  That  pathogenic  micro- 
organisms can  pass  from  the  mother  to  the  foetus  has  been  proved  partly 


§  59.]  MICRO-OEGANISMS.  281 

by  cases  of  anthrax  infection  which  have  occurred  in  man,  and  partly  hy 
experiments  upon  animals  (chicken  cholera,  septiccsmia  in  rabbits,  malig- 
nant oedema).  Birch-Hirschfeld  has  made  a  careful  microscopic  study  of 
the  placenta  in  pregnant  goats,  rabbits,  white  mice,  and  bitches  suffering 
from  anthrax,  and  he  found  the  bacilli  in  both  the  placenta  and  in  the  foetal 
tissues,  but  in  very  different  amounts  in  the  difPerent  animals  experimented 
upon.  He  affirms  that  the  healthy  placenta  will  not  ordinarily  permit  of  the^ 
direct  passage  into  the  foetal  circulation  of  either  finely  divided  foreign  bodies^ 
incapable  of  increase  in  numbers,  or  of  micro-organisms ;  but  the  j^lacenta, 
without  necessarily  undergoing  any  gross  mechanical  changes  (rupture  of 
the  chorionic  villi  or  of  the  maternal  vessels,  hajmorrhag-es),  may  become 
pervious  from  the  effects  produced  by  the  micro-organisms  circulating- 
through  it.  Micro-organisms,  such  as  the  anthrax  bacilli,  can,  when  present 
in  vast  numbers,  penetrate  into  the  foetal  portion  of  the  placenta  if  assisted 
by  alterations  in  the  tissues  forming  the  walls  of  the  blood  sinuses,  and  by 
lesions  in  the  epithelium  of  the  villi.  These  changes  can  be  brought  about 
by  the  injurious  effects  due  to  the  growth  of  the  bacteria.  (See  also  §  83,. 
Tuberculosis.) 

Non-pathogenic  Bacteria. — C.  Frankel  gives  the  following  as  the  prin- 
cipal non-pathogenic  bacteria  :  1,  Micrococcus  prodigiosus ;  2,  Bacillus  indi- 
cus ;  3,  yellow,  white,  orange,  and  red  sarcinae ;  4,  Bacillus  megaterium  ;  5, 
potato  bacillus;  6,  Bacillus  subtilis;  7,  Bacillus  figurxms \  8,  Bacillus  acidi 
lactici;  9,  Bacillus  hutyricus,  Clostridium  bufi/ricus;  10,  bacillus  of  blue- 
milk  ;  11,  bacteria  of  drinking-water  {Bacillus  violaceus,  Bacillus  fluores- 
cens) ;  12,  Bacillus  phosphorescens ;  1^,  Bacterium  phosphor escens;  14, 
Bacterium  termo ;  15,  Proteus  vulgaris ;  16,  Bacillus  spinosus ;  17,  Spiril- 
lum rubrum ;  18,  Spirillum  centricum.  For  further  description  of  these,, 
reference  should  be  made  to  the  text-books  of  Fliigge,  C.  Frankel,  and  others. 

Pathogenic  Bacteria. — The  pathogenic  bacteria  are  the  following :  1,  Ba- 
cillus anthracis ;  2,  bacillus  of  malignant  oedema ;  3,  bacillus  of  pseudo- 
cedema;  4,  bacillus  of  tuberculosis;  5,  bacillus  of  leprosy;  6,  bacillus  (?)  of 
syphilis ;  7,  bacillus  of  glanders  {Bacillus  mallei) ;  8,  Comma  bacillus  of 
Asiatic  cholera ;  9,  Finkler-Prior's  vibrio ;  10,  Deneke's  vibrio ;  11,  Vibrio- 
Metschnikoff;  12,  Emmerich's  bacillus;  13,  bacillus  of  typhoid;  14,  spiril- 
lum of  relapsing  fever  (typhus  recurrens) ;  15,  Plasmodium  malarice ;  16» 
Friedliinder's  capsule  bacillus  ;  17,  FrdnkeVs  pneumococcus  ;  18,  bacillus  of 
diphtheria;  19,  bacillus  of  rhinoscleroma ;  20,  streptococcus  of  erysipelas; 
21,  Staphylococcus  pyogenes  aureus;  22,  and  citreus;  23,  and  albus;  24, 
Streptococcus  pyogenes  ;  25,  Bacillus pyocyaneus;  26,  gonococcus  ;  27,  bacil- 
lus of  tetanus ;  28,  bacillus  of  chicken  cholera ;  29,  bacterium  of  ha^mor- 
rhagic  septicemia  (rabbit  septicEemia,  swine  fever) ;  30,  bacillus  of  swine 
erysipelas ;  31,  bacillus  of  mouse  septicaemia ;  32,  Micrococcus  tetragenus^ 
Bacterium  coli  commune,  etc. 

I  shall  refer  again  to  the  bacteria  whieli  are  of  the  most  importance 
from  a  surgical  standpoint  under  the  chapters  dealing  with  the  infec- 
tious diseases  of  wounds. 

The  Mycetozoa  and  Protozoa.— We  must  briefly  discuss  the  mycetozoa 

and  protozoa  which,  according  to  the  latest  investigations,  also  play  an  im- 


282 


IxNFLAMMATION   AND   INJURIES. 


portant  part  in  the  pathology  of  man  and  animals.  The  mycetozoa  or  myxo- 
mycetes  are  neither  animals  nor  plants,  but  a  group  of  living  organisms 
midway  between  the  two,  though  nearer  to  the  amoeba3,  the  lowest  form  of 
animal  life,  than  to  the  bacteria,  or  most  elementary  plants.  The  young 
mycetozoa  form  slimy  masses  of  protoplasm  (plasmodia),  changing  later  into 
vesicles  with  an  enveloping  membrane  containing  spores,  and  particularly 

zoospores,  which  move  about  partly  by  means 
of  a  waving  llagellum  (Fig.  273,  d,  e)  and  part- 
ly by  the  pushing  out  and  drawing  in  of  proto- 
plasmic processes  (Fig.  273,  /).  The  zoospores 
multiply  for  many  generations  by  division  of 
the  cell  into  two  parts,  and  finally  two  or 
more  of  these  cells  join  and  fuse  together, 
forming  again  a  protoplasmic  body,  or  Plas- 
modium, as  it  is  called.  The  mycetozoa,  the 
chief  representatives  of  which  are  myxomy- 
cetes  and  the  small  group  of  acrasia,  grow 
upon  the  decaying  parts  of  plants,  algaj,  etc. ; 
they  are  typical  saprophytes,  though  some 
lead  a  parasitic  life  in  plants.  The  plasmo- 
diophora  Brassicse  produce  a  destructive  tu- 
mour-like disease  in  the  roots  of  cabbage.  The 
mycetozoa  and  micro-organisms  related  to 
them  are  also  pathogenic  for  man  and  ani- 
mals. Koch  surmised  this  long  ago,  but  it  has 
only  recently  been  proved. 

The  Protozoa. — The  mycetozoa  come  next 
to  the  protozoa,  which  are  usually  looked  upon 
as  the  lowest  forms  of  animal  life,  but  are 
not  sharply  defined  from  the  lowest  forms  of 
plants.  The  protozoa  consist  partly  of  a  single 
cell,  partly  of  several  similar  cells,  with  a  dis- 
tinct differentiation  of  their  protoplasms.  They  pass  through  several  stages 
of  development,  as  exemplified  by  the  amoeba?,  which  are  similar  to  the 
white  blood-corpuscles,  and  which  multiply  by  division,  beginning  with  the 
nucleus. 

Leuckart  divides  the  protozoa  into  rhizopods.  sporozoa,  and  infusoria. 
The  rhizopods  consist  of  unenclosed  protoplasmic  masses  containing  vacuoles 
and  a  nucleus.  They  multiply  by  division,  live  in  solid  nutritive  media, 
and  move  by  putting  forth  finger-like  processes  (pseudopodia).  The  sporozoa 
move  about  like  worms,  by  expansion  and  contraction ;  they  multiply  by 
means  of  spores,  and  live  as  parasites ;  they  are  nourished  by  fluids  which 
pass  by  endosmosis  through  the  cuticular  envelope  of  the  cell.  The  gregarines, 
living  as  parasites  in  insects  and  worms,  belong  to  the  sporozoon  class,  as  do 
also  the  oval  psorosperms  (coccidia.  Fig.  274),  which  lead  a  parasitic  existence 
in  mammals,  and  the  cylindrical  psorosperms,  found  in  fishes  and  amphibia. 
The  infusoria  belong  to  the  last  division  of  protozoa ;  they  do  not  change 
their  shape ;  they  possess  cilia  and  an  opening  which  answers  for  a  mouth, 
and  their  protoplasm  is  made  up  of  a  cortical  and  medullary  portion. 


Fig.  273.—/?,  young  plasmodium 
from  ehondriodei-ma  ditforme, 
containing  two  spores  ;  a,  unjer- 
niinated  spore  (trichia  vera); 
b-d,  exit  of  the  zoospores  from 
the  torn  spore  membrane ;  e,  cili- 
ated, /,  non-ciliated  amoeboid 
zoospores  (De  Barry). 


60.] 


GENERAL  REMARKS  CONCERNING  INJURIES. 


283 


It  has  been  proved  by  recent  experiments  that  both  the  mycetozoa  and 
protozoa  are  pathogenic  as  regards  man.  Golgi,  in  Paris  (1886),  showed 
that  peculiar  amoeboid  bodies  were  regularly  present  in  the  blood  during 
intermittent  fever  and  malaria,  and  were  almost  always  to  be  found 
inside  the  red  blood-corpuscles,  in  which  they  underwent  lively  amoeboid 
movements. 

Numerous  observers  have  established  the  fact  that  this  organism  can  be 
demonstrated  in  the  blood  in  every  case  of  malaria  (the  Plasmodium  mala- 
rice).     It  has  hitherto  been  impossible  to  cultivate  the  Plasmodium  malarice 


o%i 


Fig.  274.— Coccidia  from  the  intestine  of  a  mouse;  method  of  intracellular  and  extracellular 
development.  The  oval,  circular,  or  sickle-shaped  embryos  (spores  a  and  a'-)  wander  into 
the  epithelial  cells  (6),  where  they  grow  into  ripe  coccidia  witli  a  capsule;  these  spherical 
coccidia  (c)  finally  break  up  again  into  free  spores  {a^). 


artificially,  but  Celli  and  Marchiafava  have  produced  malaria  in  healthy 
individuals  by  the  intravenous  injection  of  blood  taken  from  malarial 
patients  and  containing  the  plasmodium.  This  fact  does  not  necessarily 
prove  the  pathogenic  significance  of  the  Plasmodium  Tnalarice,  but  it  has 
been  established  beyond  a  doubt  by  other  experiments  that  this  organism  is 
the  real  cause  of  the  malarial  fever.  It  has  also  been  proved  that  some  severe 
forms  of  dysentery  are  due  to  a  peculiar  amoeba  (Kartalis,  in  Virch.  Archiv, 
Bd.  105,  p.  531),  and  molluscum  contagiosum  to  a  species  of  plasmodium. 
There  have  also  been  found  mycetozoa  and  protozoa  within  the  cells  in 
various  skin  diseases,  cutaneous  ulcers,  and  malignant  tumours.  In  fact, 
sarcoma  and  carcinoma  are  probably  caused  by  protozoa  (sporozoae).  Among 
the  latest  investigations  in  this  direction  those  of  Jiirgens  deserve  especial 
attention  (see  Tumours)  * 

§  60.  General  Remarks  concerning  Injuries. — The  injuries  of  the 
human  body  are  divided  into  tv70  main  groups :  injuries  with  and  in- 
juries without  interruption  of  the  continuity  of  the  external  coverings 
of  the  body,  including  both  skin  and  mucous  membrane.  The  former 
class  we  designate  as  open  bleeding  injuries,  or,  in  short,  as  wounds ; 
the  latter  as  bloodless  or  subcutaneous  injaries.  This  distinction  is  of 
the  greatest  practical  importance,  since  the  prognosis  of  any  injury, 
*  See  also  PfeifEer,  Die  Protozoen  als  Kranklieitserreger. 


284  INFLAMMATION  AND  INJURIES. 

apart  from  tlie  influence  of  the  particular  portion  of  the  body  involved, 
is  chiefly  dependent  upon  whether  the  overlying  skin  or  mucous  mem- 
brane lias  been  divided  or  not.  Evei-y  open  wound,  be  it  ever  so  small 
— for  example,  the  prick  of  a  needle — may  be  the  cause  of  an  infectious 
wound  disease,  and  under  these  circumstances  may  prove  fatal  to  the 
patient.  It  must  always  be  borne  in  mind,  as  we  have  learned  in  §  59, 
that  the  micro-organisms  which  are  everywhere  present  outside  the 
body  may,  by  their  admission  to  any  wound,  give  rise  to  the  gravest 
dangers.  This  cannot  occur  in  subcutaneous  injuries  where  the  pro- 
tecting skin  and  mucous  membrane  remain  intact  and  ordinarily  jjre- 
vent  the  entrance  of  these  noxious  bodies  into  the  system.  The  aim 
of  the  modern  method  of  treating  wounds  is  directed,  as  it  should  be, 
towards  keeping  out  of  the  wound  all  injurious  substances,  including 
bacteria,  and  towards  rendering  them  innocuous  in  case  they  have 
gained  entrance.  A  probe  or  a  finger  which  has  not  been  disinfected 
may  cost  the  patient's  life.  In  the  chapter  on  Fractures  we  shall  see 
that  in  the  pre-antiseptic  periods  of  surgery  the  course  of  subcutaneous 
fractures  was  entirely  different  from  that  of  fractures  complicated  by 
wounds  of  the  skin.  It  was  in  the  treatment  of  this  latter  class  of 
injuries  that  Joseph  Lister,  the  great  reformer  of  modern  surgery, 
began  the  practical  application  of  his  antiseptic  or  antibacterial  method 
of  treating  wounds.  Now  we  are  enabled  to  keep  a  fresh  wound  free 
from  all  injurious  substances — ^in  other  words,  to  prevent  all  infectious 
wound  diseases — and  to  bring  about  a  cure  of  a  great  number  of 
injuries  which  in  the  pre-antiseptic  days  would  undoubtedly  have 
proved  fatal. 

According  to  the  causation  of  the  injury,  we  distinguish  between 
injuries  due  to  mechanical  violence  and  those  due  to  thermal  (burning, 
freezing)  or  chemical  influences  (cauterisation).  Subcutaneous  injuries 
are  produced  by  blows  with  blunt  instruments,  or  falls,  while  open 
wounds  are  caused  by  blows  with  more  or  less  sharp  instruments,  and 
take  the  form  of  punctured,  lacerated,  incised,  contused,  or  gunshot 
wounds,  etc.  All  wounds  due  to  blows  with  blunt  instruments  are 
more  or  less  contused  wounds — that  is,  the  borders  of  the  wounds 
suffer  a  more  or  less  extensive  crushing  or  necrosis  as  a  result  of  the 
violence  used. 

The  pure  incised,  stab,  and  punctured  wounds  are  simple  wounds, 
while  the  lacerated  and  contused  wounds  are,  as  we  shall  see,  compli- 
cated wounds.  The  condition  of  the  borders  and  the  depth  of  the 
wound  are  matters  of  great  practical  importance.  If  a  wound  pene- 
trates into  a  joint  or  into  one  of  the  large  cavities  of  the  body,  such  as 
the  cranial,  thoracic,  or  peritoneal  cavities,  we  call  it  a  penetrating 


§60.]  GENERAL  REMARKS  CONCERNING  INJURIES.  285 

wound.  If  a  portion  of  tissue  is  completely  cut  or  torn  from  its  con- 
nections by  violence,  a  wound  is  formed  with  loss  of  substance ;  but  if 
the  portion  of  tissue  still  retains  some  of  its  connections  with  the  sur- 
rounding parts,  there  results  what  is  called  a  flap  or  peel  wound.  A 
wound  which  is  clean,  not  poisoned  and  not  infected,  is  distinguished^ 
from  one  which  is  unclean,  poisoned,  and  infected.  "We  count  among 
unclean  wounds  all  those  in  which  there  is  present  any  foreign  body 
whatsoever,  such  as  dust,  sand,  dirt  of  every  description,  portions  of 
clothing,  bullets,  powder  grains,  etc.  Wounds  affected  with  any  one 
of  the  infectious  wound  diseases  belong  to  the  class  of  infected  wounds 
(inflammation,  suppuration,  erysipelas,  wound  diphtheria,  septicaemia, 
etc.).  The  wounds  produced  by  bites  of  snakes,  insects,  etc.,  are  infected 
by  animal  poisons. 

The  symptomatology  and  treatment  of  injuries  vary  greatly,  accord- 
ing to  the  portion  of  the  body  involved  and  the  anatomical  peculiari- 
ties of  the  injured  tissues.  Consequently  we  divide  injuries  of  the 
human  body  into  injuries  of  soft  parts,  of  bones,  and  of  joints,  and 
their  symptomatology  and  treatment  will  be  discussed  later  on.  We 
shall  first  give  a  general  outline  of  the  anatomical  changes  occurring  in 
the  healing  of  a  wound. 

Railway  Injuries. — A  very  severe  and  common  class  of  injuries  are 
incurred  from  collisions  between  railway  trains.  Tardieu,  Vibert,  and  others 
Lave  recorded  their  valuable  experiences  on  this  subject,  particularly  Vibert, 
who  gave  a  report  of  four  hundred  jDersons  injured  in  a  railway  accident 
at  Charenton.  The  occupants  of  the  train  which  moves  the  most  rapidly 
suffer  the  worst  and  most  numerous  injuries.  Upon  those  who  die  instantly 
without  exhibiting  any  external  injury  many  punctiform  haemorrhages  are 
found,  mostly  about  the  head  and  upper  portions  of  the  body,  similar  to 
those  which  occur  in  fracture  of  the  base  of  the  skull.  Bad  fractures  and 
injuries  to  the  soft  parts  are  found  chiefly  on  the  lower  extremities,  unless 
the  victims  protect  themselves  in  time  by  rising  from  their  seats.  Not  in- 
frequently the  lungs  are  injured  (haemoptysis)  by  contusion  or  crushing  of 
the  thorax,  and  there  may  also  be  injuries  of  the  abdominal  viscera.  Very 
often  the  patients  suffer  grave  disturbances  of  the  central  nervous  system — 
loss  of  sleep,  headache,  alterations  in  their  mental  condition  of  a  partly 
excitable,  partly  melancholic,  depressed  type,  disturbances  of  digestion,  loss 
of  memory,  easily  excited  intellectual  fatigue,  great  susceptibility  towards 
stimulants  (alcohol,  tobacco),  maniacal  conditions,  auditory  disturbances, 
photophobia,  paralysis  of  accommodation,  disturbances  of  smell  and  taste, 
paraesthesia  of  the  sensory  nerves,  anaesthetic  areas,  particularly  when  there 
is  an  organic  lesion  of  the  brain,  muscular  tremor,  motor  weakness,  espe- 
cially in  the  legs,  paralyses,  disturbances  of  circulation  and  respiration,  and 
increasing  cachexia.  The  patient  exhibits,  in  some  cases,  every  symptom  of 
paralytic  dementia.  All  these  nervous  phenomena  are  grouped  together 
under  the  name  of  traumatic  neuroses.    They  are  particularly  liable  to  make 


286  INFLAMMATION  AND  INJURIES. 

their  appearance  after  concussion  of  the  brain  and  spinal  cord,  and  some- 
times are  caused  by  relatively  slight  accidents.  In  the  majority  of  cases  it 
is  a  psychosis  and  neurosis,  similar  to  hysteria,  without  actual  changes  in  the 
central  nervous  system  (Charcot,  Striimpell).  Albin  Hoffmann  has  correctly 
pointed  out  that  a  traumatic  neurosis  is  of  much  less  frequent  occurx'ence  in 
individuals  previously  perfectly  healthy  than  has  hitlierto  been  supposed; 
the  number  of  malingerers  is  lai'ge,  and  is  steadily  increasing  since  the 
accident  law  went  into  effect.  In  the  minority  of  the  cases  there  do  occur 
progressive  pathological  changes  in  the  central  nervous  system  as  a  direct 
result  of  the  accident.  The  prognosis  of  these  cases  is  very  unfavourable ; 
they  often  lead  to  chronic  disease  of  the  cortex  of  the  brain  :  less  frequently 
it  is  located  in  the  spinal  cord.  The  English  physicians  have  given  the 
name  of  railway  spine  to  the  secondary  diseases  of  the  central  nervous 
system  following  railway  accidents.  The  treatment  of  traumatic  hysteria, 
or  railway  spine,  belongs  to  the  province  of  the  neurologists. 

Dynamite  Explosions  (i. e.,  the  union  of  nitroglycerine  with  silicic  acid 
in  different  proportions)  give  rise  to  very  sevei'e  injuries.  Owing  to  the 
I'apidity  of  the  explosion  the  wounded  do  not  suffer  anj-  burns,  but  the 
wounds  are  very  I'ed,  bleed  a  good  deal,  and  either  resemble  incised  wounds 
or  they  are  badly  lacerated.  Hairy  portions  of  the  body  have,  in  conse- 
quence of  the  action  of  the  acid,  a  white  colour,  and  are  not  black,  as  in 
explosions  of  powder.  The  injuries  to  the  bones  are  extremely  severe,  the 
fragments  being  scattered  throughout  the  body.  Pieces  of  the  metacarpal 
bone  have  been  found,  for  example,  in  the  thorax,  and  a  torn-off  finger-nail 
in  the  body  of  the  first  vertebra  (Rochard).  The  eyes  not  infrequently  suffer 
severe  secondary  disturbances. 

§  61.  The  Anatomical  Phenomena  in  the  Healing  of  a  Wound. — The 

anatomical  phenomena  manifested  in  the  healing  of  wounds  have  been 
studied  chiefly  by  Thiersch,  Gussenbauer,  Recklinghausen,  Ziegler, 
Marchand,  and  others.  We  distinguish  two  kinds  of  repair  in  a 
wound :  (1)  the  direct  primary  agghitination  of  the  divided  parts, 
called  healing  per  pinmam  inientumem ;  and  (2)  the  repair  of  a 
wound  by  the  formation  of  granulation  tissue,  or,  in  other  words, 
repair  accompanied  by  suppuration,  called  healing  per  secundam  in- 
tentionem.    ■ 

Healing  per  Primam  Intentionem. — Healing  by  primary  intention 
takes  place  in  all  fresh  aseptic  wounds,  particularly  in  those  produced 
in  the  course  of  an  operation,  the  borders  of  the  latter  class  (operation, 
wounds)  being  held  by  the  stitches  in  continual  contact  until  they  ad- 
here together.  Those  wounds  which  are  treated  aseptically  heal  more 
rapidly  than  those  treated  antiseptically — that  is,  than  the  wounds  irri- 
tated by  antiseptic  solutions  (bichloride,  carbolic  acid,  etc.). 

Macroscopic  Phenomena  in  Healing  by  Primary  Intention. — The 
macroscopic  phenomena  manifested  in  the  healing  of  wounds  per  pri- 
onam  intentionem  are  briefly  as  follows :  We  ordinarily  find,  in  the 


§61.]  ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.    287 

first  place,  that  the  borders  of  the  wound  become  agglutinated  by  a 
coaguluni  made  up  of  blood  and  lymph.  During  the  next  four,  six, 
or  eight  days  the  union  of  the  wound  is  definitely  established,  the 
coagulum  in  and  around  the  wound  space  becoming  replaced  by  new 
cells  and  blood-vessels,  the  former  of  which  gradually  change  into  the 
fibrillar  connective  tissue  making  up  the  cicatrix.  In  the  case  of 
small  wounds,  or  slight  losses  of  substance,  there  is  usually  developed 
as  a  result  of  the  coagulation  of  the  blood  and  lymph  a  crust,  beneath 
which  the  complete  healing  of  the  wound  is  accomplished  (healing 
under  a  scab,  see  page  180).  The  skinning  over  of  the  wound  proceeds 
from  its  borders  by  proliferation  of  the  cells  of  the  rete  Malpighii 
and  of  the  sebaceous  glands,  if  the  latter  still  exist  in  the  surface  of 
the  wound.  The  young  cicatrix  at  first  forms  a  fine  red  line,  which 
subsequently  becomes  gradually  whiter  and  softer.  The  cicatrices  of 
many  wounds  which  unite  by  primary  intention  disappear  in  course  of 
time  more  or  less  completely. 

Healing  by  Secondary  Intention. — The  healing  i)er  secundarn  inten- 
tionerii^  with  the  formation  of  granulation  tissue,  takes  place  in  badly 
contused  wounds,  or  where  there  has  been  a  loss  of  substance  and  it 
has  been  impossible  to  obtain  direct  adhesion  of  the  divided  tissues 
with  the  aid  of  stitches,  and  also  in  wounds  which  have  been  neglected 
and  not  treated  aseptically,  and  in  wounds  which  have  been  infected 
by  micro-organisms. 

Macroscopic  Phenomena  in  the  Healing  of  Wounds  by  Secondary  In- 
tention.— Macroscopically,  the  phenomena  which  take  place  in  this 
form  of  healing  of  a  wound,  involving,  for  example,  vascular  soft  parts, 
are  somewhat  as  follows :  Until  the  expiration  of  about  twenty-four 
hours  after  the  reception  of  the  injury  the  various  tissues  exposed  in 
the  surface  of  the  wound  are  clearly  distinguishable  from  one  another. 
Later  on  the  outlines  of  the  various  tissues  in  the  wound  are  obscured 
by  a  gelatinous  covering,  and  the  wound  secretes  a  reddish-yellow  fluid, 
a  mixture  of  blood  serum  and  lymph.  After  about  two  to  three  days- 
the  greyish-red  gelatinous  wound  surface  begins  to  take  on  a  granular, 
red  appearance,  and  the  wound  begins  to  granulate,  or  to  form  vascu- 
lar cellular  germinal  tissue  called  granulation  tissue,  from  which  there 
is  ordinarily  produced  an  exudate  containing  a  great  quantity  of  round 
cells — in  other  words,  pus. 

In  contused  wounds  with  destruction,  or  rather  necrosis,  of  the 
tissues,  the  dead  portion  of  the  tissues  is  first  cast  olf  by  the  process  of 
granulation  ;  the  wound  "  purifies  itself."  Under  these  conditions  heal- 
ing without  profuse  secretion  or  suppuration  is  more  likely  to  occur  the 
sooner  after  the  injury  the  wound  is  disinfected  and  dressed  aseptically. 


:288 


INFLAMMATION  AND  INJURIES. 


The  Skinning  Over  of  a  Granulating  Wound. — The  covering  over  of 
a  granulating  surface  with  skin  proceeds  gi-adually  from  the  margins 
of  the  wound,  and  is  accompanied  by  a  simultaneous  shrinkage  of  the 
granulation  tissue.  If  the  cutis  has  not  been  entirely  destroyetl,  if 
there  are  still  traces  of  the  Malpighian  stratum  present,  or  if  the  epi- 
thelium of  the  sebaceous  glands  is  intact,  the  remains  of  these  struc- 
tures will  form  the  starting  points  within  the  granulating  area  from 
which  skin  will  spread  outwards  over  the  granulating  surface.  All 
cicatrices  which  are  accompanied  during  their  formation  by  suppura- 
tion are  thicker,  broader,  and  more  unsightly  than  the  small  linear 
cicatrices  resulting  from  primary  union. 

All  wounds,  even  those  produced  in  au  aseptic  operation  and  those  that 
have  healed  aseptically,  contain  bacteria.  The  secretion  in  the  wound  and 
the  diminished  power  of  absorption  of  the  latter  ai'e,  however,  important 
factors  in  the  prevention  of  the  invasion  and  further  development  of  bac- 
teria. Furthermore,  we  know  that  the  blood,  particularly  the  serum,  fur- 
nishes protection  to  the  organism  against  bacteria. 

Histological  Phenomena  in  the  Healing  of  Wounds. — The  minute  phe- 
nomena which  take  place  in  the  repair  of  a  wound  involving  vascu- 
lar tissue  is  practically  the  same 
"whether  the  wound,  heals  with  the 


'?? 


jFig.  275. —  Wound  in  the  liver  ("cuneiform  ex- 
cision), twenty-four  hours  old :  a,  Border 
of  the  liver;  6,  blood-clot  in  the  defect. 
Commeucincf  collection  of  wandering  cells 
in  the  borders  of  the  wound. 


Fig.  276 — Immiofiated  ^\hite  blood-corpu-cles 
in  a  four-cornered  defect  in  the  middle  of 
a  dead,  hai-dened  piece  of  liver  substance, 
"which  had  been  implanted  with  antiseptic 
precautions  in  the  abdominal  cavity  of  a 
rabbit  twenty-four  hours. 


formation  of  pus  or  without  it.     Healing  by  primary  intention  is  char- 
acterised by  the  formation  of  a  minimum  amount  of  germinal  tissue 


;  61.]  ANATOMICAL  PHENOMEIS'^A  IN  THE  HEALING  OF  A  WOUND.    289 


Fig.  277. — Wound  in  the  kidney  on  the  fourth  day.  Large  forma- 
tive cells,  varying  in  shape  (b).  a,  Extravasation  of  blood, 
with  here  and  tliere  masses  of  protoplasmic  formative  mate- 
rial ((.')  produced  by  a  fusion  of  the  white  blood-corpuscles. 


uniting  the  borders  of  the  wound,  while  in  healing  by  secondary  inten- 
tion the  amount  of  germinal  tissue  is  much  more  considerable.  After 
every  wound,  no  matter  how  free  the  healing  may  be  from  reaction, 
there  follows  an  in- 
flammation in  the 
sense  described  in 
§  56,  and  as  a  result 
of  this  there  is  a  cel- 
lular infilti'ation  of 
the  borders  of  the 
wound  with  wander- 
ing cells  (Fig.  275). 
This  cellular  infiltra- 
tion of  the  borders 
of  the  wound  stead- 
ily progresses,  ad- 
vancing by  degrees 
into  the  wound,  and 
taking  the  place  of 
the  blood  coagulum 
which  is  present  (Fig. 
276).  In  cases  of 
pronounced  inflammatory  infiltration  of  the  borders  of  the  wound  the 
old  tissues  in  the  immediate  neighbourhood  are  more  or  less  completely 
destroyed  by  fatty  degeneration.  On  about  the  third  day  the  wound, 
or  the  wound  cleft,  will  be  found  filled  vdth  a  tissue  consisting  almost 
exclusively  of  round  cells,  with  a  very  small  amount  of  intermediate 
substance,  while  here  and  there  are  scattered  the  remains  of  the  blood 
coagulum.  Later  on  there  will  be  found  large  epithelioid  cells  (Figs. 
277,  278),  the  actual  formative  cells  of  the  granulation  tissue  or  cica- 
trix— ^fibroblasts  as  they  are  called — which  change  into  the  fibrils  of  the 
fibrillar  connective  tissue  (Fig.  278,  a).  I  used  to  believe  that  these 
formative  cells  were  direct  descendants  of  the  emigrated  white  blood- 
corpuscles,  but  recent  discoveries  have  forced  me  to  abandon  this  view 
as  incorrect,  and  I  have  come  to  the  conclusion  that  Thiersch,  Reck- 
linghausen, and  others  are  right  in  stating  that  the  original  fixed  con- 
nective-tissue cells  and  the  endothelium  of  the  vessels  are  the  essential 
factors  in  the  formation  of  the  cicatrix.  Ziegler  has  also  recently 
adopted  this  view.  IS^uclei  in  different  stages  of  division  can  be  dem- 
onstrated in  the  fixed  connective-tissue  cells  and  the  endothelium  of 
the  vessels  as  they  undergo  rapid  proliferation.  The  newly  formed 
tissue  cells  can  also  become  wandering  cells.  The  regenei^ative  pro- 
20 


290 


INFLAMMATION  AND   INJURIES. 


cesses  within  the  injured  organs  ai-e  likewise  carried  on  by  the  fixed 
tissue  cells.  The  connective-tissue  cell  always  gives  rise  to  a  new 
connective-tissue  cell,  an  epithehal  cell  to  an  epithelial  cell,  but  a  con- 
nective-tissue cell  is  never  formed 
from  an  epithelial  cell,  or  vice  ver- 
sa. The  leucocytes  present  either 
perish — i.  e.,  are  either  absorbed  b*y 
the  growing  tissue  cells,  particu- 
larly the  polynuclear  leucocytes — 
or  they  wander  back  into  the  cir- 
culation as  in  inflammation.  On 
the  other  hand,  I  believe  that  some 
of  the  protoplasm  of  the  wandei-- 
ing  cells  is  employed  as  cell  mate- 
rial in  both  the  scar  formation  and 
the  regenerative  processes  carried 
on  in  the  original  fixed  tissue  cells. 
I  am  unable  to  say  whether  the 
white  blood-corpuscles  can  them- 
selves form  fibrillar  connective  tis- 
sue when  the  circulation  is  suffi- 
ciently active,  for  example,  in  a 
granulating  wound ;  but  their  im- 
portance in  this  respect  is  much 
less  than  that  of  the  fixed  tissue 
cells — i.  e.,  the  cells  of  the  connec- 
tive tissue  and  the  endothelium  of 
the  vessels  which  have  been  dem- 
onstrated to  be  the  real  producers 
of  the  scar  and  are  called  fibro- 
blasts. Reinke  and  others  believe 
that  further  development  is  possible  in  those  wandering  cells  which 
make  their  appearance  after  the  proliferation  of  the  fixed  cells  has 
begun,  and  which  exhibit  great  vital  energy.  Ribbert  considers  it 
probable  that  the  lymphogenic  leucocytes  with  a  single  nucleus  are 
capable  of  taking  part  in  the  formation  of  new  connective  tissue 
by  helping  to  cover  over  the  lymph  cavities  and  spaces  with  endo- 
thelium. 

New  Formation  of  Tissue  according  to  Ziegler,  Marchand,  Tillmanns. — 

Ziegler  was  the  first  to  make  an  exhaustive  study  of  the  manner  in  which 
new  tissue — the  fibrillary  connective  tissiie — is  formed.  He  fitted  together 
two  pieces  of  glass,  about  ten  to  twenty  millimetres  long  and  ten  millimeti'es 


Fig.  278. — Fifth  day  ;  a  piece  of  hardened  liver 
with  a  defect  in  the  middle  ;  large  forma- 
tive cells  which  have  developed  from  tixed 
tissue  cells;  a,  clearly  defined  tilirillury 
connective  tissue  formed  from  cells ;  6, 
masses  of  protoplasmic  formative  material 
with  commencing  differentiation  seen  by 
the  appearance  of  larger  nuclei;  c,  solid 
sprouts  from  the  vessels ;  d,  blood-vessel. 


§  61.]  ANATOMICAL  PHENOMENA  IN  THE  HEALING  OP  A  WOUND.    291 

broad,  and  made  them  adherent  to  each  other  at  the  corners  with  porcelain 
cement,  leaving  an  empty  space,  accessible  by  capillarity  from  the  sides,  into 
which  the  white  blood-corpuscles  and  the  lymphatic  fluid  could  penetrate 
after  the  glass  plates  had  been  placed  beneath  the  skin  or  periosteum  or 
inside  one  of  the  cavities  of  the  body  of  an  animal.  The  plates  were  left  in 
place  inside  the  animal  from  ten  to  twenty-five  to  fifty  days,  and  when 
removed  were  gently  washed,  and  then  placed  for  two  days  in  a  0.1-per-cent. 
solution  of  hyperosmic  acid,  after  this  in  spirits  of  glycerine,  and  finally  in 
pure  glycerine.  My  own  method  consists  in  hardening  in  absolute  alcohol 
pieces  of  lung,  liver,  and  kidney,  measuring  about  one  cubic  centimetre,  and 
making  holes  and  notches  in  them,  and  then  placing  them  with  every  anti- 
septic precaution  in  the  peritoneal  cavity  of  a  rabbit.  Sections  are  after- 
wards cut  from  these  specimens,  and  when  examined  under  the  microscope 
will  give  a  very  beautiful  picture  of  the  new  formation  of  tissues.  Ziegler 
came  to  the  conclusion  that  the  emigrated  white  blood-corpuscles  undergo 
further  development,  and  form  fibrillar  connective  tissue  if  there  is  a  suffi- 
cient circulation  of  lymphatic  fluid,  and  especially  if  enough  nutrition  is 
supplied  by  the  development  of  new  vessels.  Ziegler  has  also,  like  myself, 
modified  this  view.  We  now  know  that  in  Ziegler's  glass  plates,  and  in  my 
pieces  of  dead  tissue,  the  new  tissue  is  chiefly  developed  from  the  cells  of  the 
newly  formed  vessels.  Salzer  has  also  made  recent  investigations  upon  the 
healing  up  in  a  wound  of  foreign  bodies,  and  Marchand  particularly  has 
made  some  very  valuable  experiments  both  in  the  healing  in  of  foreign 
bodies  and  in  the  new  formation  of  tissue.  Marchand  employed  chiefly  bits 
of  sponge,  cork,  elder-wood  pith,  and  pieces  of  lung  and  liver  injected  with 
blue  gelatine,  which  he  buried  in  the  peritoneal  cavities  of  guinea-pigs  and 
rabbits.  After  four  to  seven  hours  a  development  of  a  network  of  fibrin 
and  an  emigration  of  numerous  leucocytes  took  place.  After  twenty-four  to 
thirty  hours,  and  later,  the  foreign  body  became  intimately  connected  with 
the  peritonaeum,  and  within  it  were  found  new  cell-forms  derived  from  the 
fixed  elements  in  the  neighbourhood,  these  cells  being  mostly  spindle-shaped, 
with  large,  elongated  nuclei,  though  round  cells  are  also  present.  All  these 
cells  spring  from  the  endothelium  of  the  peritonaeum,  the  fixed  connective- 
tissue  cells,  and  the  cells  of  the  walls  of  the  vessels,  etc.,  in  which  the  nuclei 
are  seen  forming  variously  shaped  figures  in  the  process  of  their  segmenta- 
tion. There  are  also  present  giant  cells,  often  having  an  extraordinary  num- 
ber of  nuclei.  The  giant  cells  are  formed  by  the  fusing  together  of  fixed 
tissue  cells,  and  possess  the  power  of  absorbing  leucocytes  ;  but  they  exhibit 
no  progressive  development,  and  later  on  perish  by  fatty  degeneration.  Giant 
cells  are  only  found  in  those  foreign  bodies  (bits  of  sponge,  elder  pith)  whose 
absorption  presents  difficulties ;  and  Marchand  did  not  discover  them  in  the 
pieces  of  lung,  as  the  tissue  of  which  it  consists  is  readily  destroyed,  and  can 
be  absorbed  by  the  leucocytes.  The  granulation  cells  are  likewise  the  off- 
spring of  the  fixed  tissue  cells,  and  not  of  the  single  or  polynucleated  leuco- 
cytes. Moreover,  the  offspring  of  the  fixed  tissue  cells  very  often  become 
wandering  cells.  Marchand  saw  segmentation  figures  in  the  nuclei  of  the 
mononuclear  leucocytes.  The  polynucleated  leucocytes  develop  from  those 
with  a  single  nucleus,  and  are  retrogressive  in  nature.  The  leucocytes  take 
no  part  in  the  formation  of  new  tissues,  but  they  do  take  part  in  the  forma- 


292  INFLAMMATION  AND  INJURIES. 

tioii  of  fibrin  wliicli,  according  to  Marchand,  is  produced  by  substances  liber- 
ated by  the  death  of  the  white  blood-corpuscles.     (See  also  page  297.) 

Sherrington  and  Ballance  maintain  that  the  cicatrix  is  formed  from  the 
cells  of  the  plasma,  these  cells  being  supplied  with  nourishment  by  the  proto- 
plasm of  the  white  blood-corpuscles.  According  to  Grawitz,  the  so-called 
dormant  cells  play  an  important  part  in  repair.  These  are  cells  which  are 
previously  iiivisible  in  the  basement  substance  of  the  tissues  and  suddenly 
become  visible — i.  e.,  develop  anew  when  the  process  of  repair  begins.  The 
multiplication  of  these  dormant  cells  gives  rise  to  embryonic  germinal 
tissue,  from  which  the  new  fibrillary  tissue  of  the  scar  is  formed.  (See  also 
page  295.) 

The  Formation  of  Fibrillar  Connective  Tissue, — Ziegler's  and  my 
own  experiments  sliow  that  the  fibrillar  couneetive  tissue — or,  in  other 
words,  the  cicatrix — is  formed  from  the  fibroblasts  in  the  following 
waj :  The  formative  cells  are  at  first  round,  and  then  enlarge,  and  look 

like     laro;e,     round 

..  .^f-^v^jr^-    ;-  jr         - :  ;      ,:■:-•-   .r^--    ..^-....^.         cpithelium  ;  or  thcj 

"         /         i  -5  "^              ,  "V      '  :,          are    more    elon^at- 

•,  ■ .  '---  ■-■  '  '  xflii  '^  ^  .     \    '?-/ 1-  '■■    y    '■■■  -5           1 

>;           '\    :f.«;j-    ,       ?s^  ^^    ;.  '-.■-■  \      ed,  or   possess   one 

;<:,.   .-'-■■    -/ef^^k:),  i-f^  i-  -^.;-   ^  r  ^  ■                     ,f    ^i         '         ^ 

crv  -■;•:  ■'  i0>^'^w^'-'  ^     '-  '  ;;  ;a           a    ■    ^    -      *      or   more    processes, 

^^  ■-•■■:.-:  Ci^M  ■•     '^      31  f  ^t    :    ■    'j  '^                          t            .     ' 

■■-■'-■- r:-'-'^  'W^i^-         /       "■  ■'  '   ;           some        becoming 

7s-''^i:':  'WW'^'^-  ^  ■■     -         ^i    s         ■'■■I   j;     spindle-shaped,  oth- 

^     r      ;   -i        y     f     ■    '^     ^  ii)     ei"s  club-shaped;  or 


sm^s'^-e^*;-"  /    '^MMh.   'i,  '-         "K       '      h'-"^^  \'^\     ^^^®^      ™^y      form 
gl^^?:  Jj^hBiiifc:--    ^^.  /l-iMiSiMli      branching   cells    or 

Fig.  279. —  Wound  in  the  liver  in  the  stage  of  cicatrisation,  tenth      polvnuclear        giant 
day:  a,  Young  cicatricial  tissue  ;  i,  liver  tissue  which  has  par-  -,,        ^pi 

tially  undergone  fatty  degeneration  in  the  neighbourhood  of       CCllS,     i  he  prOCeSSCS 

putcSr*'''''  "'"'^  ""'''"''''  '"'"^  '"^  '"''^  ^'^""'^  biood-cor-  repeatedly  anasto- 
mose with  one  an- 
other. The  number  of  the  large  formative  cells  then  rapidly  increases, 
and  in  certain  localities  they  lie  close  together.  The  fibrillar  tissue  is 
formed  in  pai't  directly  from  the  protoplasm  of  the  formative  cells, 
and  is  consequently  intracellular  in  its  origin,  or  it  comes  from  a 
homogeneous  intercellular  ground  substance  or  stroma  which  has  pre- 
viously developed  from  the  formative  cells.  In  the  inti*acellular  fibre- 
formation  fibres  make  their  appearance  on  one  or  both  sides  of  a  cell, 
or  at  one  extremity  of  it,  or  in  a  process,  and  unite  with  the  fibres  of 
the  adjoining  cells.  The  nucleus,  together  with  a  portion  of  the  pro- 
toplasm of  the  formative  cell,  persists  as  a  fixed  connective-tissue  cell 
(Figs.  278,  a,  279).  The  direction  taken  by  the  fibres  is  usually  the 
same  over  a  considerable  area,  the  formative  cells  playing  no  j^art  in 
determining  the  direction  of  the  fibres.  As  illustrated  in  Fig.  279,  the 
cicatrix  is  in  the  beginning  rich  in  large  elongated  cells,  the  remains  of 


61.]  ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.    293 


the  earlier  formative  cells,  which  in  part  become  changed  into  fibres. 
The  size  of  these  cellular  remains  subsequently  diminishes,  the  fibrous 
tissue  becomes  thick- 


er,  and  the  cicatrix 
is  complete  (Figs. 
280,  281,  282). 

New  Formation 
of  Vessels. — The  for- 
mation of  new  ves- 
sels proceeds  hand 
in  hand  with  the 
above-described  tis- 
sue formation.  In 
fact  it  is  this  that 
renders  possible  the 
further  development 
of  the  accumulated 
formative  cells ;  and 
the  cells  of  the  new- 
ly formed  vessels 
also  contribute  very 

essentially  to  the  formation  of  the  new  tissue  which  makes  up  the  cica- 
trix.    In  the  earliest  stages  in  the  repair  of  a  wound,  the  formative 
cells,  or  the  cells  of  the  granula- 
tion tissue,  receive  their  nutriment  ^^/|g^7'  N'  'f^l'^iWh^ 


Fig.  280. — Fourteenth  day  ;  cicatrised  defect  (a)  iu  a  piece  of  dead, 
)iardened  lung  (b) ;  the  latter  is  tilled  with  numerous  wander- 
ing and  formative  cells,  especially  in  the  neighbourhood  of 
the  defect,  or  rather  the  cicatrix. 


oY 


f  / 


Fig.  281. — Seventeenth  day  :  cicatrised  defect 
(a)  in  a  piece  of  a  dead,  hardened  liver 
(i)  implanted  within  the  ahdominal  cav- 
ity of  a  rabhit. 


Fig.  282. — Twenty-eighth  day  ;  healed  wound 
in  the  liver,  cicatrix  (aj  containing  blood 
pigment. 


from  the  stream  of  plasma  escaping  from  the  vessels  in  the  neighbour- 
hood. As  Thiersch  has  shown,  this  intercellular  circulatory  system  can 
be  injected  through  the  blood-vessels.     But  this  arrangement  for  sup- 


294 


INFLAMMATION   AND   INJURIES. 


plying  nutritiou  to  the  cells  is  only  temporary,  and  the  formation  of 
new  blood-vessels  is  required  for  the  further  process  of  repair  in  a 
wound. 

The  development  of  new  blood-vessels  is  the  result  of  an  actual 
sprouting  from  the  walls  of  pre-existing  vessels  (Figs.  278,  283,  284j. 
There  is  first  noticed  on  the  external  surface  of  a  capillary  loop  a  gran- 
ular accumulation  of  j)rotoplasm,  which  graduallj-  enlarges  (Fig.  283. 
a,  h,  c)  and  grows  into  a  solid  protoplasmic  filament,  which  contains  a 
nucleus.     This  protoplasmic  filament,  simple  (Fig.  283, y)  or  branched 

^  (Fig.  283,  d,  e,  g), 
joins  either  with  the 
wall  of  another  ves- 
sel, or  unites  with  an- 
other similar  spi'out 
advancing  in  the  op- 
posite direction  and 
springing  from  an- 
other similar  capil- 
lary loop  (Fig.  283, 


Fig.  283. — Development  of  blood-vessels  by  budcling ;  different  forms  of  buds,  a,  b,  c,  First 
stages;  d.f,  j7,  simple  and  brauchincr  solid  buds;  e,  vascular  bud  which  is  being  made  hol- 
low and  which  already  contains  blood-corpuscles. 


d^  y,  g).  There  are  also  formed,  not  infrequently,  protoplasmic  fila- 
ments which  turn  back  in  an  arch  to  the  same  vessels  from  which  they 
started.  Furthermore,  processes  from  the  spindle-  or  clul)-shaped  or 
branching  formative  cells  of  the  intercapillary  tissue  join  with  the 
sprouts  from  the  walls  of  the  vessels,  and  thus  the  material  in  the 
formative  cells  helps  in  the  formation  of  the  new  blood-vessels.  After 
a  certain  length  of  time  the  originally  solid  protoplasmic  filaments 
become  hollow  from  liquefaction  of  their  interior,  giving  rise  to  an 
open  communication  with  the  mother  vessels,  while  the  daughter  ves- 


§61.]  ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.    295 


sels  become  more  and  more  hollowed  out  and  gradually  filled  with 
blood  from  the  mother  vessels.  Not  infrequently  an  open  pouch  (Fig. 
283,  h)  develops  at  the  very  outset  from  the  wall  of  the  vessel,  gradu- 
ally tapering  off  into  ^ 
a  filament  of  proto-  ,  !  / »  \  /'Ji/|  |y 
plasm.  The  walls  of 
the  daughter  vessel, 
the  newly  developed 
capillary,  are  at  first 
homogeneous,  later  on 
nuclei  are  added,  and 
they  take  on  a  plain- 
ly recognisable  cellular 
structure,  consisting  of 
flat  cells  (endothelial 
cells).  Subsequently 
the  walls  of  the  vessel 
are  strengthened  mate- 
rially by  the  formative 
cells  in  the  neighbour- 
liood. 

The  above  -  men- 
tioned protoplasmic  fil- 
aments shooting  out  from  the  walls  of  the  vessels  are  made  up  partly 
of  the  cells  of  the  vessel  walls,  and  partly,  as  I  believe  I  have  ob- 
served, of  white  blood-corpuscles  which  have  passed  through  the  capil- 
lary wall.  At  a  later  period  a  shrinkage  takes  place  in  the  newly 
formed  connective  tissue  of  the  cicatrix,  and  a  portion  of  the  vessels 
disappear,  causing  the  original  red  scar  to  become  pale. 

The  manner  in  which  the  wound,  or  rather  the  granulating  surface, 
is  covered  with  skin,  has  been  briefly  stated  above.  For  the  purpose 
of  healing  over  large  granulating  surfaces,  Eeverdin  employed  the 
transplantation  of  small  particles  of  skin.  This  method  of  skiu  trans- 
plantation was,  however,  first  made  a  useful  procedure  by  Thiersch 
(see  §  42).  For  a  description  of  the  histological  changes  occurring  in 
the  union  of  transplanted  pieces  of  skin,  see  page  149. 

Reunion  of  Entirely  Severed  Portions  of  the  Body. — Parts  which  have 
been  completely  severed  from  all  their  connections  with  the  body  may 
again  become  united  in  the  same  manner  as  the  skin  grafts  of  Kever- 
din  and  Thiersch.  But  this  is  only  possible  in  the  case  of  small  por- 
tions of  tissue,  such  as  the  tip  of  the  nose  or  of  the  fingers.  To  these 
phenomena  belong  the  reposition  of  teeth  which  have  been  extracted. 


Fig.   284.— Development   of  new  blood-ve.ssels  by   budding. 
Seventeenth  day.     Wound  in  the  liver. 


296  INFLAMMATION  AND  INJURIES. 

the  transplantation  of  living  or  dead  bone  or  cartilage  into  defects  in 
bone,  etc.  The  success  of  all  these  operations  is  dependent  npon  the 
strictest  observance  of  the  rules  of  asej^sis.  The  transplantation  of  the 
various  tissues  above  mentioned  has  been  described  on  page  150. 

The  Formation  of  d  Cicatrix  in  a  Vessel,  or  the  Organisation  of  a 
Thrombus. — The  formation  of  a  cicatrix  in  a  vessel  which  has  been 
wounded  or  ligated  is  of  special  importance. 

The  following  is  a  brief  description  of  the  manner  in  which  the  thrombus 
forms  in  a  vessel :  Since  Briicke  made  his  famous  experiments,  we  know 
that  the  blood  is  kept  fluid  within  the  walls  of  the  vessels  because  of  its  con- 
tact with  a  normal  endotlielium,  and  because  of  its  constant  movement.  If 
either  one  of  these  two  conditions  is  lacking,  if  the  integrity  of  the  endothe- 
lium of  the  vessels  is  altered  in  any  way  by  an  iuiiaminatioii  or  traumatism, 
if  the  blood  escapes  from  the  walls  of  the  vessels,  or  if  its  circulation  is  inter- 
rupted— for  example,  by  ligation  of  the  vessel — the  blood  will  then  coagulate ; 
it  will  form  a  thrombus. 

The  thrombus  which  develops  after  ligation  of  an  artery-,  for  example, 
extends  from  the  point  at  which  the  ligature  has  been  applied  to  the  nearest 
lateral  branch  above  and  below.  The  same  holds  true  as  regards  the  veins. 
We  know,  however,  that  in  a  vein  extensive  thrombi  form  much  more  readily 
than  in  an  artery,  and  this  is  the  case  not  only  when  the  lumen  is  occluded 
by  a  ligature  or  an  injury,  but  also  when  there  occurs  a  pronounced  stasis 
and  obstruction  to  the  return-flow  of  the  blood.  If  two  ligatures  are  api)lied 
to  a  vessel  with  a  moderate  interval  between  them,  the  blood  will  coagulate 
between  these  ligatures ;  but  a  thrombus  does  not  always  develop  after  the 
ligation  of  a  vessel.  Baumgarten  demonstrated  that  the  blood  lying  between 
two  ligatures  may  remain  fluid  for  three,  four,  or  even  twelve  to  fifteen  days 
if  the  ligation  is  carefully  j)erformed,  and  particularly  if  the  wall  of  the 
vessel  is  not  isolated  from  its  connections  with  the  adjoining  tissues,  and  if 
its  nutrition  from  the  vasa  vasorum  is  not  interfered  with.  Under  such  con- 
ditions the  endothelium  appears  to  remain  intact  and  performs  its  functions 
normally,  and  consequently  the  blood,  though  not  moving,  retains  its  fluid 
character. 

In  wounds  or  injuries  involving  only  a  portion  of  the  circumference  of 
a  vessel  there  is  not  always  the  formation  of  a  thrombus  filling  the  entire 
lumen  of  the  vessel.  The  rent  in  the  wall  is  often  completely  filled  by  a 
thrombus  which  organises,  leaving  only  a  thickening  of  the  vessel  at  the  site 
of  the  injury.  This  method  of  repair  may  take  place  in  vessels  of  any  size 
whatsoever.  Again,  a  thrombus  which  at  the  outset  only  partially  fills  the 
lumen  may  finally  cause  its  total  occlusion  by  the  addition  to  it  of  one  layer 
of  coagulum  after  another. 

We  have  to  deal  mainly  with  thrombi  occui-ring  after  an  injury  or  the 
ligation  of  a  vessel.  Mention  should  also  be  made  of  the  so-called  compres- 
sion thrombi,  which  form  when  the  blood  is  brought  to  a  standstill  as  a  re- 
sult of  compression  from  without,  as  by  tumours ;  of  the  dilatation  thrombi  in 
aneurysms  and  varices ;  of  the  thrombi  caused  by  inflammatory  processes  in 
the  walls  of  the  vessels  accompanied  by  destruction  of  the  endothelium,  etc. 


§61.]  ANATOMICAL  PHENOMENA  IN  THE  HEALING  OP  A  WOUND.    29T 

But  changes  in  the  walls  of  the  vessels  and  primary  disturbances  in  the 
circulation  are  not  always  sufficient  in  themselves  to  produce  coagulation  of 
the  blood  ;  the  cause  for  the  thrombosis  must  be  sought  for  not  infrequently 
in  a  general  alteration  in  the  composition  of  the  blood.  Silberman  has  seen, 
multiple  coagula  form  during  life  from  acute  poisoning  by  the  salts  of  hydro- 
chloric acid,  arsenic,  phosphorus,  and  several  other  blood  poisons.  On  the 
other  hand.  Arthus  proved  that  by  depriving  the  blood  of  its  calcium  it  loses 
its  power  of  coagulation. 

Red,  White,  and  Mixed  Thrombi.— There  are  red,  white,  and  mixed 
thrombi.  The  formation  of  a  white  thrombus  by  an  accumulation  of  white 
blood-cells  can  be  watched  under  the  microscope  by  irritating  with  a  crystal 
of  common  salt  placed  in  its  neighbourhood,  some  large  artery  or  vein  lying 
in  the  spread-out  mesentery  or  tongue  of  a  curarised  frog.  At  the  point  of 
irritation  the  inner  wall  of  the  vessel  becomes  covered  with  white  blood-cor- 
puscles, and  a  white  immovable  plug  gradually  develops,  filling  the  entire 
lumen  of  the  vessel  by  a  constant  addition  of  new  white  corpuscles  to  those 
already  in  place.  Some  investigators  claim  that  the  white  thrombi  described 
by  Zahn  are  not  formed  from  white  blood-coi-puscles,  but  from  the  blood 
plaques  discovered  by  Bizzozero,  those  very  small,  delicate,  colourless,  disk- 
shaped  bodies  which  constitute  the  third  formed  ingredient  of  the  blood. 
The  origin  of  the  blood  plaques,  which  can  be  stained  with  methyl  violet 
while  in  a  neutral  common-salt  solution,  is  still  obscure,  and  their  signifi- 
cance is  still  a  matter  of  controversy.  The  average  number  of  plaques  in 
human  blood  is  245,000  per  cubic  millimetre.  Their  number  is  sometimes 
increased  and  sometimes  diminished  in  different  diseases.  Eberth  and  Schim- 
melbusch  make  a  sharp  distinction  betw^een  the  white  thrombi  of  blood 
plaques  and  the  red  blood-clots ;  the  blood  plaques,  according  to  these  authori- 
ties, having  nothing  to  do  with  the  formation  of  fibrin,  and  simply  adhere 
together  at  some  injured  point  of  the  intima  as  a  result  of  their  peripheral 
location  in  the  blood  stream  when  there  is  any  marked  retardation  in  the 
flow  of  the  current.  They  also  hold  that  a  thrombus  is  not  identical  with  a 
blood  coagulum,  the  thrombi  being  not  red,  like  the  ordinary  coagulum,  but 
either  entirely,  or  for  the  most  part,  white. 

Coagulation  of  the  Blood. — There  are  many  views  as  to  the  manner  in 
which  coagulation  of  the  blood  takes  place.  Alexander  Schmidt  and  his 
followers,  reasoning  from  numerous  experiments,  explain  coagulation  of  the 
blood  in  the  following  manner :  The  fibrin  results  from  the  union  of  two 
fibrin  generators,  the  fibrinogen  and  the  paraglobulin,  brought  about  by  the 
action  of  the  fibrin  ferment.  The  fibrinogen  exists  in  solution  in  the  blood 
plasma ;  the  fibrin  ferment  and  the  paraglobulin  ai^e  first  liberated  by  the 
disintegration  of  the  white  blood-corpuscles,  and  then  have  the  power  of 
acting  upon  the  fibrinogen.  As  long  as  the  white  blood-corpuscles  circulate 
uninjured  in  the  blood  a  coagulum  cannot  form.  In  the  blood  of  birds  and 
amphibia  the  disintegrated  red  (nucleated)  corpuscles  furnish  the  fibrin-mak- 
ing substances.  The  blood  in  immediate  contact  with  the  living  and  normal 
walls  of  a  vessel,  as  we  have  said,  does  not  coagulate ;  but  if  the  walls  are 
altered  by  pathological  processes  or  mechanical  injury — if,  for  example,  the 
intima  becomes  changed  by  inflammation,  if  it  becomes  roughened,  uneven, 
swollen,  torn,  etc. — a  blood-clot  will  form  at  these  points  even  while  the  cir- 


298  INFLAMMATION  AND   INJURIES. 

oulation  still  continues.  Blood  which  has  escaped  from  a  wounded  vessel 
will  immediately  coagulate,  as  will  blood  within  the  heart  or  a  vessel  after 
death.  Moreover,  by  the  disintegration  of  white  blood-cells  which  takes 
place  under  normal  circumstances  in  healthy,  cii'culating  blood,  some  fibrin 
ferment  develops  (Schmidt,  Jakovvicki,  Birk) ;  this  is  the  case  especially  in 
venous  blood.  It  is  furthermore  an  interesting  fact  that  in  septictcmia  and 
pyaemia  the  amount  of  the  fibrin  ferment  resulting  from  the  disintegration 
of  the  white  blood-corpuscles  can  be  so  increased  as  to  give  rise  to  the  spon- 
taneous formation  of  coagula  (Kohler  and  others).  On  the  other  hand,  fever 
is  produced  (Wahl,  Bergmann,  Angerer)  by  the  absorption  of  the  fibrin  fer- 
ment from  the  extravasated  blood  after  operations  or  subcutaneous  injuries 
(fractures).  Hauser,  who  studied  microscopically,  by  means  of  Weigert's 
method  of  staining  fibrin,  the  formation  of  the  latter  in  pathologically 
altered  tissues  and  vessels,  also  found  that  the  fibrin  ferment  was  formed 
from  degenerating  cells  (leucocytes,  tissue  cells,  and  perhaps  also  blood 
plaques  and  bacterial  cells)  and  the  fibrinoplastic  materials  from  its  plasma. 

Bizzozero,  on  the  other  hand,  ascribes  the  formation  of  fibrin  solely  to  the 
dissolution  of  the  blood  plaques  and  their  derivatives  (Zimmermann's  cor- 
puscles), and  he  denies  that  the  white  blood-corpuscles  have  any  part  in  the 
process.  Haym  also  claims  that  the  cause  of  the  coagulation  of  the  blood 
when  a  vessel  is  injured  is  to  be  sought  for  in  what  he  calls  the  "ha^mato- 
blasts  "  (Bizzozero's  "  blood  plaques  ").  These  small,  very  easily  altered  cellu- 
lar elements  in  the  blood  become  immediately  changed,  according  to  Haym, 
when  a  foreign  body  comes  into  contact  with  them,  or  when  the  intima  of  the 
vessel  loses  its  integrity  by  pathological  processes  or  mechanical  influences. 

Wooldridge  made  some  very  exhaustive  experiments  upon  the  subject  of 
coagulation  of  the  blood,  under  Ludwig's  guidance,  in  the  Physiological 
Institute  at  Leipsic,  and  he  states  that  Alexander  Schmidt's  explanation  of 
coagulation  of  the  blood  is  correct  only  to  a  very  limited  extent,  if  at  all. 
Wooldridge  disputes  the  necessity  of  the  co-operation  of  the  formed  elements 
of  the  blood  in  the  process  of  coagulation,  and  asserts  that  the  blood  plasma 
itself,  free  from  all  formed  elements,  contains  everything  which  is  necessary 
for  the  production  of  coagulation.  The  plasma  is  caused  to  coagulate  by  two 
bodies  contained  in  it,  which  are  a  combination  or  mixture  of  albumen  and 
lecithin,  and  are  called  by  Wooldridge  A-  and  B-flbrinogen.  He  states  that 
certain  substances  (albuminous  bodies  containing  a  very  large  percentage  of 
lecithin)  which  have  a  marked  power  of  producing  coagulation  can  be  iso- 
lated from  the  testicle,  lymph  glands,  the  chyle,  brain,  thymus,  and  stroma 
of  the  red  blood-corpuscles.  He  does  not  attach  any  importance  to  the  fibrin 
ferment  as  a  cause  of  coagulation. 

Our  knowledge  of  the  coagulation  of  the  blood  has  been  recently  enriched 
by  some  exceedingly  interesting  facts  discovered  by  the  important  investiga- 
tions made  by  Marcus  Arthus.*  Arthus  found  that  by  the  addition  to  the 
blood  of  oxalate  of  ammonia— i.  e.,  by  decalcification  of  the  blood — the  latter 
loses  its  power  to  coagulate ;  but  if  chloride  of  calcium  is  again  added  in 
excess  the  blood  then  immediately  coagulates.     From  this  it  follows  that 

*  Marcus  Arthus.  Theses  presentees  a  la  faculte  des  sciences  de  Paris.  Paris :  H. 
Jouve,  rue  Racine,  15. 


§61.]  AjSTATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.    299 

the  calcium  in  the  blood  has  a  fibriuoplastic  action,  and  that  the  fibrin  fer- 
ment and  the  fibrinogen  only  act  in  the  presence  of  calcium  salts.  Arthus 
states  that  the  salts  of  strontium  have  the  same  effect  as  those  of  calcium, 
and  consequently  there  is  also  a  strontium  fibrin.  This  makes  it  necessary 
for  us  to  recognise  many  different  kinds  of  fibrin.  Arthus  maintains  that 
the  teachings  of  Schmidt  and  Hammerstein  should  be  modified  to  the  extent 
of  making  three  factors  necessary  for  the  coagulation  of  blood,  viz.,  the  fibrin 
ferment,  fibrinogen,  and  lime  salts.  The  coagulation  of  the  blood  may  be 
compared  to  the  coagulation  of  cheese  from  milk,  the  caseine  corresponding 
to  the  fibrinogen,  the  curdling  ferment  to  the  fibrin  ferment,  and  the  cheese 
to  the  fibrin.  According  to  Pekelharing,  fibrin  ferment  is  itself  a  calcium 
compound  which  is  capable  of  transferring  calcium  to  the  fibrinogen,  so 
that  the  soluble  fibrinogen  gives  rise  to  an  insoluble  compound  of  albu- 
men containing-  calcium,  viz.,  fibrin. 

Freund  maintains  that  the  coagulation  of  the  blood  is  brought  about  by 
the  undissolved  phosphate  of  calcium.  The  phosphates  and  potassium  salts 
preponderate  in  the  blood-corpuscles,  the  sodium  and  calcium  salts  in  the 
serum.  When  the  blood  comes  in  contact  with  a  foreign  body  and  ceases  to 
touch  the  walls  of  the  vessel,  the  phosphates  in  the  blood-corpuscles  unite 
with  the  calcium  salts  in  the  serum,  forming  a  large  amount  of  phosphate  of 
calcium,  which  does  not  all  remain  in  solution. 

The  Varying  Reaction  of  the  Leucocytes  to  Staining  Substances.— The 
colourless  blood-corpuscles  (leucocytes)  vary  in  their  reaction  to  staining 
materials — a  matter  of  great  diagnostic  importance  (Ehrlich).  While  the 
nuclei  of  all  leucocytes  are  coloured  by  the  well-known  aniline  dyes  used 
for  staining  nuclei,  the  protoplasm  of  the  cells  behaves  differently,  possessing 
for  particular  dye-stuffs  a  greater  or  less  affinity.  The  leucocytes  differ  also 
in  size  and  in  the  number  of  their  nuclei  (mono-  or  poly  nucleated).  The 
majority  of  the  leucocytes  (about  seventy  per  cent,  of  the  colourless  blood, 
corpuscles)  form  the  polynucleated  leucocytes,  the  granules  in  which  are 
neutral  (neutrophilar) — i.  e.,  their  protoplasm  is  only  susceptible  of  being 
stained  by  neutral  dyes,  such  as,  for  example,  a  neutral  mixture  of  a  basic 
and  acid  aniline  dye  (methylene  blue  and  the  so-called  acid  fuchsin).  A 
smaller  number  of  the  leucocytes  (about  five  per  cent,  to  eight  per  cent.)  in 
the  blood  are  eosinophilar  or  acidophilar  cells — in  other  words,  the  granules 
of  their  protoplasm  are  capable  of  being  stained  bright  red  by  the  acid  dye 
eosin.  The  acidophilar  or  eosinophilar  granules  are  coarser  than  the  neutro- 
philar ;  the  cells  also  are  perceptibly  larger  than  the  neutrophilar,  and  for 
the  most  part  possess  one  or  two  nuclei  of  considerable  size.  The  third  class 
of  leucocytes,  which  are  rare— mostly  mononucleated  cells— possess  a  proto- 
plasm which  is  only  capable  of  being  stained  by  basic  aniline  dyes  (baso- 
philar  leucocytes).  The  fourth  class  of  leucocytes,  mostly  small  mononu- 
cleated cells  with  a  narrow  or  broad  enveloping  band  of  protoplasm,  are 
partly  neutrophilar  and  partly  capable  of  being  stained  by  acid  as  well  as 
basic  aniline  dyes  (amphophilar).  Mosso  *  has  made  an  exhaustive  study 
upon  the  change  of  the  red  blood-corpuscles  into  leucocytes  and  the  necro- 
biosis of  the  red  blood-corpuscles  in  coagulation  and  suppuration. 


*Virch.  Arch.,  Bd.  109,  1887. 


300 


INFLAMMATION    AXD   INJURIES. 


Changes  in  the  Thrombus. — Aftei-  a  thrombus  has  formed,  the  fur- 
ther points  in  its  history  which  are  of  interest  are  (1)  its  organisation 
into  soHd  connective  tissue  containing  hlood-vessels,  or,  in  other  words, 
the  formation  of  a  cicatrix,  and  (2)  the  softening  of  the  thrombus, 
The  organisation  of  the  thrombus  into  connective  tissue  containing 
vessels  is  the  most  desirable  termination  :  but  softening  of  the  throm- 
bus, particularly  its  suppurative  breaking  down,  brought  about  by  the 
action  of  bacteria  and  accompanied  by  subsequent  embolic  processes,  is 
always  dreaded  by  the  surgeon.  Thanks  to  the  aseptic  method  of 
operating  and  treating  wounds,  this  infectious  softening  or  breaking 
down  of  a  thrombus  is  of  infrequent  occurrence  in  modern  surgery. 
TTe  shall  treat  of  the  infectious  softening  of  thrombi  more  in  detail 
Avhen  we  come  to  diseases  of  wounds.  The  calcification  of  a  thrombus 
from  deposition  of  lime  salts  is  another  comparatively  satisfactory 
change  which  a  thrombus  may  undergo.  The  so-called  phleboliths 
are  calcitied  thrombi  which  have  formed  in  veins. 

Organisation  of  a  Thrombus  and  Cicatricial  Closure  of  a  Vessel. — AVe 
are  here  concerned  %vith  the  question  of  the  organisation  of  the  throm- 
bus into  connective  tissue,  and  the  formation  of  a  cicatrix  within  a 

vessel.  The  minute  changes  are 
practically  the  same  as  we  have 
described  above,  and  they  apply 
to  the  arteries  as  well  as  the 
veins.  According  to  Thiersch, 
Thoma,  and  others,  the  closure 
of  a  vessel,  the  so-called  organi- 
sation of  the  thrombus,  or,  more 
correctly,  the  sul)Stitution  for  the 
thrombus  of  connective  tissue,  is 
mainly  brought  about  by  a  pro- 
Hferation  of  the  endothelium  of 
the  intima.     All  the  authorities 

Organisation  of  a  thrombus ;  jr,  media  agree    that     the    thrombuS    itself 

mtiltrated  with  cells;   /,   intima   infiltrated  ^ 

■nith   cells:   B,  variously  shaped  formative  plavs  nO  part  in  the  formation  of 

cells  resulting  from  the  proliferation  of  the  "      .    •      •                     i       • ,  •             i 

endothelial  cells  of  the  vessels  and  employed  ^  Cicatrix  111  a  vessei  ;    it  IS  gradu- 

in  the  organisation  of  the  thrombus  (forma-  „]]       ;;nnnlantpr1    bv   flip    cplbilar 

tion  ot  the  cicatrix  in  the  vessel; :  T/^,  throm-  ^      .-^uppidniea    0}     lue    ceilUiar 

^'^*-    ''  ^^^-  infiltration,    which    then    forms 

fibrillar  connective  tissue.  At 
first  variously  shaped  formative  cells  (Fig.  285)  develop  by  the  pro- 
liferation of  the  endothelium  of  the  vessels,  and  these  subsequently 
change  into  fibrillar  connective  tissue.  These  cells  penetrate  the 
thrombus   in   all  directions;   the  connective  tissue   developing   from 


Fig.  285 


§61.]  ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.   301 


them  becomes   steadily  stronger,  and   finally  takes  the    place  of   the 

At  the  conclusion  of  the  pro- 


fO^^ 


.*** 


V  y-i:^'  ■ 


X 


// 


Fio.  286. — Organised  vascular  thrombus 
in  a  piece  of  dead  kidney.  Nine- 
teenth day.  In  the  centre  are  a 
newly  formed  blood-vessel  and  a 
giant  cell.  The  adventitia  of  the 
wall  of  the  vessel  contains  many  leu- 
cocytes, but  the  muscular  coat  not  so 
many.     Gentian,  Canada  balsam. 


thrombus  throughout  its  whole  extent. 
cess  there  only  remains  of  the  thrombus 
a  few  granular  masses  of  brown  pig- 
ment— hsematogenous  pigment,  proba- 
bly hydroxide  of  iron.  Simultaneously 
with  this  endothelial  proliferation  and 
growth  of  cells  into  and  throughout  the 
thrombus  the  latter  becomes  vascular- 
ised  by  the  formation  of  new  vessels. 
If  a  thrombus  does  not  completely  oc- 
clude the  lumen  of  a  vessel,  its  organi- 
sation takes  a  longer  time  than  when 
the  vessel  is  completely  plugged  by  the 
thrombus  (Baumgarten).  The  cicatrix 
is  formed  from  the  cellular  germinal 
tissue  in  the  manner  we  have  described 
on  page  288.  The  vascularisation  of 
the  thrombus — i.  e.,  the  formation  of 
new  vessels  within  it — takes  its  start 
chiefly  from  the  point  at  which  the 
intima  has  been  broken  or  torn.  The  vasa-vasorum,  on  account  of 
the  diminution  of  the  pressure  in  the  interior  of  the  vessel,  grow 
through  the  relaxed  walls  into  the  lumen  of  the  vessel  (Benecke,  Ack- 
ermann). 

The  minute  changes  which  take  place  in  the  organisation  of  a  thrombus 
can  be  studied  very  satisfactorily  by  placing,  with  every  antiseptic  precau- 
tion, a  segment  of  a  vessel  which  has  been  previously  hardened  in  absolute 
alcohol  inside  the  peritoneal  cavity  of  a  rabbit  (Seuftleben,  Tillmanns). 
There  will  be  observed  a  steadily  increasing  emigi'ation  of  colourless  blood- 
corpuscles  into  the  wall  and  interior  of  the  vessel,  or  rather  into  the  throm- 
bus ;  at  the  same  time  there  will  be  a  corresponding  new  formation  of  vessels 
from  the  germinal  cellular  tissue,  which  is  developed  from  the  endothelium 
of  the  newly  formed  vessels  and  not  from  the  white  blood-corpuscles,  and 
finally  the  thrombus  becomes  supplanted,  in  the  manner  already  described, 
by  vascular  fibrillar  connective  tissue,  and  the  vessel  is  closed  by  a  cicatrix 
(Fig.  286). 

The  length  of  time  required  for  the  cicatricial  closure  of  a  vessel 
to  take  place  by  the  organisation  of  a  thrombus  varies  very  much.  In 
young  subjects  the  reparative  process  is  in  general  more  rapid  than  in 
old  individuals,  and  it  is  slowest  in  the  case  of  patients  aiflicted  with 
chronic  (atheromatous)  degeneration  of  the  intima  of  the  vessels.  In 
animals  which  have  been  experimented  upon,  vascular  tissue  will  be 


302 


INFLAMMATION  AND   INJURIES. 


found  at  the  site  of  the  throinl)us,  or  rather  where  tlie  ligature  has 
been  apphed  to  the  vessel,  at  the  end  of  the  second  week,  and  possibly 
even  earlier,  by  the  seventh  to  the  eighth  day.  During  the  third  to 
the  fifth  week  the  cicatrix  in  the  vessel  becomes  completely  formed, 
though  in  some  cases  the  process  takes  ninch  longer.  In  course  of 
time  the  cicatrix  in  a  vessel  shrinks  like  any  other  scar.  If  the  cica- 
trix shrinks  in  the  centre,  the  scar,  or  rather  the  vessel,  may  again 
become  pervious,  so  that  the  final  result  may  be  merely  a  diminution 
in,the  lumen  of  the  vessel,  with  a  thickening  of  its  wall.  In  still  other 
cases  the  cicatrix,  as  a  result  of 
dilatation  of  the  vessel  in  which 
it  lies,  may  become  perforated  by 
several  small  isolated  vessels  con- 


FiG.  287. — Collateral  circulation  (after  ligation 
of  an  artery  in  its  continuity)  through  the 
central  and  peripheral  branches. 


Fig.  288. — Collateral  circulation  eight  months 
after  ligation  of  the  aorta  of  a  dog  (Porta). 


necting  the  central  and  peripheral  ends  of  the  artery  (Fig.  288).  The 
so-called  sinus  degeneration  (Rokitansky),  in  which  the  thrombus  is 
changed  into  a  network  of  connective-tissue  strands  having  spaces 
between  them,  is  particularly  liable  to  occur  in  thrombi  which  develop 
in  veins. 

Collateral  Circulation. — If  a  blood-vessel — an  artery,  for  example — 
is  occluded  at  some  point  by  a  ligature  or  a  thrombus,  a  collateral  cir- 
cu-lation  is  immediately  developed  by  dilatation  of  the  vasa-vasorum 
and  of  the  branches  given  off  on  the  proximal  and  distal  side  of  the 
thrombus.  This  restores  the  circulation,  and  ensures  the  nutrition  of 
the  portion  of  the  body  supplied  by  the  occluded  artery  (Fig.  287).     It 


§  61.]  ANATOMICAL  PHENOMENA  IN  THE  HEALING  OF  A  WOUND.    303 

is  interesting  to  note  the  manner  in  which  the  collateral  circulation 
becoraes  established  after  ligation  of  an  artery  in  its  continuity,  as 
illustrated  in  a  specimen  obtained  by  Luigi  Porta,  showing  the  col- 
lateral circulation  eight  months  after  ligation  of  the  abdominal  aorta  in 
a  dog  (Fig.  288). 

It  is  plain  that  the  collateral  circulation  took  place  in  this  instance 
both  through  the  dilated  vasa-vasorum  lying  between  the  two  stumps 
of  the  ligated  aorta  and  the  adjacent  lumbar  arteries,  and  branches 
made  up  partly  of  old  and  partly  of  newly  formed  vessels. 

Recently  Nothnagel  has  made  some  very  exhaustive  expei'iments  on 
rabbits  relating  to  the  establishment  of  the  collateral  circulation,  and 
he  found  that  six  days  after  applying  the  ligature  there  occurred  a 
hypertrophy  and  hyperplasia  of  the  muscular  fibres  in  the  dilated  col- 
lateral arteries.  ISTothnagel  and  Recklinghausen  explain  the  growth 
of  these  vessels  by  the  increased  rapidity  of  the  blood  current  within 
them  and  the  increased  amount  of  nutrition  which  this  brings  about. 
The  more  blood  that  passes  through  a  vessel  in  a  given  time,  the 
greater  is  the  amount  of  nutritive  material  supplied  to  the  wall  of  the 
vessel.  The  pressure  theory,  which  many  authorities  think  sufficient 
to  account  for  the  establishment  of  a  collateral  circulation,  is,  according 
to  JN^othnagel,  of  no  value. 

The  Repair  of  a  Wound  in  Non-vascular  Tissues.— The  process  of  repair 
in  a  wound,  or  the  formation  of  a  cicatrix  in  tissues  which  do  not  contain 
vessels  (cornea,  cartilage,  etc.),  is  practically  the  same  as  for  vascular  tissue. 
We  know  that  non- vascular  tissues — the  cornea,  for  example — contain  an 
intricate  communicating  system  of  canals,  in  which,  under  normal  condi- 
tions, wandering  cells  are  present  here  and  there. 

If  the  cornea  is  injured  there  occurs  an  abundant  emigration  of  white 
blood-corpuscles  from  the  adjoining  sclera  and  conjunctiva  and  from  the 
conjunctival  sac.  The  tissue  developed  from  the  inflammation — in  other 
words,  the  cicatrix — is  here  also  formed  from  the  original  fixed  cells  of  the 
cornea. 

A  cicatrix  is  formed  in  cartilage  in  precisely  the  same  way  from  the  car- 
tilage cells  in  the  neighbourhood.  The  cicatrix  resulting  fi'om  an  aseptic 
wound — i.  e.,  from  one  which  has  healed  without  reaction — will  retain  its 
fibrillar  character  for  a  great  length  of  time.  Gies  claims  that  it  retains  this 
character  permanently ;  but  if  a  severe  inflammatory  reaction  takes  place 
the  cicatrix  will  rapidly  become  hyaline,  like  normal  hyaline  cartilage  (see 
Injuries  of  Joints). 

Regeneration  of  Injured  Tissues. — In  every  injured  organ  there  is 
always  an  attempt  to  bring  about,  as  far  as  possible,  a  complete  resti- 
tutio ad  integrum.  The  regeneration  of  the  damaged  tissues  will  take 
place  the  more  rapidly  and  completely  the  more  delicate  the  cicatrix 
is— in  other  words,  the  stricter  the  asepsis  and  the  more  the  wound  is 


304  INFLAMMATION  AND  INJURIES. 

made  to  heal  bj  primarj  union  without  reaction,  and  the  less  the  cells 
peculiar  to  the  oi-gan  are  damaged.  But  the  more  highly  organised 
tissues  have  relatively  slight  jjowers  of  regenerating  themselves  after 
they  have  been  damaged.  The  epidermis,  the  epithelium  of  the 
mucous  membi'anes,  bones,  cartilage,  periosteum,  tendons,  and  other 
connective-tissue  structures,  are  capable  of  regenerating  themselves 
completely,  while,  on  the  other  hand,  losses  of  substance  in  the  various 
glands  and  in  muscle  are  not  restored,  but  their  place  is  supplied  solely 
by  scar  tissue,  in  the  manner  described  above.  Consequently,  a  cica- 
trix which  includes  the  more  deeply  lying  subcutaneous  cellular  tissue 
contains  no  sweat  or  sebaceous  glands  and  no  hair  follicles  or  hairs, 
and  a  correspondingly  extensive  cicatrix  in  the  intestine  contains  no 
follicles  and  no  glands  of  Lieberkiihn.  Moreover,  defects  or  losses  of 
substance  in  muscular  tissue  are  only  made  good,  as  already  stated,  by 
scar  tissue,  and  are  not  replaced  by  newly  formed  muscular  fibres ;  the 
fibrous  cicatrix  is  interposed  like  a  tendinous  intersection  in  the  course 
of  the  muscle  and  enables  it  to  contract.  Regeneration  of  muscular 
fibre  takes  place  only  in  the  neighbourhood  of  the  cicatrix,  and  in 
those  cases  in  which  the  injury  to  the  muscle  has  been  trifling — a  con- 
tusion, for  example.  Ponfick,  however,  has  demonstrated  that  losses 
of  substance  in  highly  organised  tissues,  such  as  the  liver  and  kidneys 
of  animals,  can  be  made  good  in  a  relatively  brief  time  by  a  new 
development  of  the  tissues  characteristic  of  the  organ. 

Of  the  more  highly  organised  tissues  the  peripheral  nerves  are  ex- 
ceptional as  regards  their  capability  of  regenerating  themselves.  After 
a  nerve  has  been  divided  and  neurorrhaphy  performed,  there  will  often 
be  a  complete  regeneration  of  the  nerve  even  w^ien  the  neurorrhaphy 
has  been  performed  several  months,  or  even  a  year,  after  the  reception 
of  the  injury.  Regeneration  has  been  brought  about  in  a  nerve  in 
which  there  has  been  a  loss  of  substance  several  centimetres  in  length 
by  suturing  together  the  divided  ends  of  the  nerve,  or  by  adopting 
other  suitable  measures,  and  now  and  then  even  spontaneously.  I  per- 
formed a  successful  neuroplasty  upon  the  median  and  ulnar  nerves  for 
a  loss  of  substance  which  they  had  suffered  several  months  previously 
(see  §  88). 

Regeneration  of  the  tissues  of  the  brain  and  spinal  cord  never  takes 
place  in  man,  though  Brown-Sequard  has  seen  regeneration  occur  in 
the  divided  spinal  cord  of  a  pigeon. 

The  manner  in  which  the  different  injured  tissues — e.  g.,  nerves, 
muscles,  bones,  etc. — are  regenerated  under  proper  treatment  will  be 
described  more  at  length  when  we  come  to  speak  of  injuries  of  these 
tissues  (see  §§  87,  88,  101). 


§  62.]   EEACTION  WHICH  FOLLOWS  INJURY  AND  INFLAMMATION.    305 

Subsequent  Pathological  Changes  in  the  Cicatrix— Cicatricial  Contrac- 
tion.— Cicatricial  contractures  ai'e  the  most  important  of  the  later  patho- 
logical changes  which  scars  undergo.  The  contraction  is,  of  course,  propor- 
tionate to  the  size  of  the  defect  or  the  amount  of  granulation  tissue.  All 
cicatrices  replacing  losses  of  substance  in  the  skin  and  the  underlying  tissues 
are  especially  liable  to  contract.  According  to  the  depth  to  which  the  loss 
of  substance  extends,  the  cicatricial  contracture  involves  only  the  skin,  or, 
besides  this,  the  deeper  parts,  especially  the  fascia,  muscles,  and  tendons. 
The  cicatricial  contractions  following  extensive  burns  are  especially  dreaded. 
The  sequelae  of  such  contractures  vary  with  the  locality  which  is  affected. 
If  one  is  situated  on  the  flexor  aspect  of  a  joint,  the  latter  will  become  fixed 
in  a  certain  degree  of  flexion  and  cannot  be  completely  extended.  Cicatricial 
shoi'tening  of  the  sterno-mastoid  muscle  causes  wry-neck  (caput  obstipum)  . 
&  scar  involving  the  under  eyelid  will  roll  the  latter  outward  (ectropion) ; 
cicatricial  contracture  of  the  cheek  will  interfere  with  the  opening  of  the 
mouth.  The  chin  and  neck  are  sometimes  fastened  firmly  together  as  a 
result  of  burns.  This  is  not  the  place  to  describe  the  treatment  for  these 
conditions,  and  it  is  only  necessary  to  state  that  they  are  now  treated  with 
excellent  results  by  methods  of  gradual  extension,  or  by  excision  of  the  scar, 
followed  by  implantation  of  Thiersch  skin  grafts,  or  of  flaps  with  pedicles 
taken,  perhaps,  from  a  widely  removed  portion  of  the  body. 

Keloids. — Occasionally  the  cicatrix  becomes  the  seat  of  a  tumour-like 
fibrous  induration  called  a  keloid.  A  thick  elevation  develops  at  the  site  of 
the  scar,  usually  with  outgrowtlis  extending  into  the  adjoining  healthy 
tissues.  This  is  really  a  hypertrophy  of  the  cicatrix.  The  cause  of  this 
keloid,  which  is  rather  rare,  is  not  understood.  After  its  extirpation  there  is 
usually  a  recurrence.  I  saw  one  case  of  cicatricial  keloid  the  size  of  a  plum, 
following  a  perforation  made  in  the  lobule  of  the  ear,  yhich  resisted  every 
kind  of  treatment  Avith  the  knife  and  red-hot  iron.  Sometimes  a  keloid  dis- 
appears by  degrees  spontaneously. 

Malignant  New  Growths. — Occasionally  malignant  new  growths,  like 
carcinomata,  may  originate  in  cicatrices.  We  shall  discuss  this  possibility 
when  we  come  to  the  etiology  of  tumours. 

Cicatricial  Ulcers. — Now  and  then  cicatricial  tissue  breaks  down  and  sup- 
purates, giving  rise  to  a  cicatricial  ulcer,  which  ordinarily  is  covered  with 
large  fungous  granulations  having  no  tendency  to  become  covered  with  skin. 
This  usually  occurs  in  weak  and  sometimes  in  tubercular  individuals,  and  is 
apt  to  start  from  some  slight  injury,  such  as  the  friction  produced  by  clothes 
might  bring  about. 

Pressure  Paralysis  of  Nerves  from  Pressure  of  the  Scar.— A  large  cicatrix 
may  exert  injurious  pressure  upon  the  blood-vessels  in  its  immediate  neigh- 
bourhood, and  may  also  cause  a  pressure  paralysis  of  the  nerves.  It  is  well 
known  that  these  pressure  paralyses  due  to  cicatrices  have,  as  a  general 
thing,  a  favourable  prognosis,  and  will  ordinarily  quickly  disappear  with 
removal  of  the  cause. 

§  62.  The  General  Eeaction  which  follows  an  Injury  and  an  Inflamma- 
tion — Fever. — The  general  condition  of  those  who  have  been  injured 
or  operated  upon  bears  a  most  intimate  causal  relationship  to  the  be- 

21 


306  INFLAMMATION  AND  INJURIES. 

liaviour  of  the  wound.  If  the  latter  heals  normally — i.  e.,  aseptieally — 
and  if  no  injarious  substances  gain  access  from  the  wound  to  the  cir- 
culating fluids  of  the  body,  there  will  usually  be  no  fever.  From  the 
fact  that  a  wound  which  heals  aseptieally,  as  a  rule,  ensures  freedom 
to  the  patient  from  a  general  febrile  disturbance,  it  follows  that  the 
febrile  disturbance  involving  the  whole  system  of  those  who  have  been 
injured  or  operated  upon  is  mainly  caused  by  the  absorption  from  the 
wound  of  injurious  substances,  the  most  important  of  which  are  the 
micro-organisms  and  the  poisonous  products  of  their  metabolism  held 
in  solution  by  the  fluids  of  the  body.  The  so-called  wound  fever  is 
really  an  absorption  fever — an  alteration  of  the  blood. 

The  fever  which  accompanies  the  so-called  internal  diseases  is  also 
in  part  an  absorption  fever,  and  the  changes  which  are  present  in  the 
blood  and  produced  by  the  bacteria,  or  rather  the  products  of  their 
metabolism  (toxines),  play  a  most  important  part  in  the  causation  of 
the  phenomenon.  Not  every  fever  is,  howevei-,  of  bacterial  origin. 
It  may  be  caused  by  the  absorption  of  certain  injurious  materials  which 
are  formed  without  the  action  of  bacteria  (see  page  313).  In  the  so- 
called  essential  fevers,  on  the  other  hand,  we  must  look  for  the  cause 
of  the  fever  in  the  central  nervous  system.  In  this  latter  class  belong 
the  febrile  disturbances  following  a  violent  fright,  the  periodic  stages 
of  excitement  in  mental  disorders,  epileptic  fits,  injuries  of  the  spinal 
cord,  etc.  These  "  nervous  fevers "  are  perhaps  caused  by  an  in- 
creased metabolism  in  the  tissues  due  to  the  excessive  nerve  irritation, 
which  raises  the  temperature  of  the  body,  or  to  diminished  loss  of  heat 
by  radiation  as  a  result  of  the  lessened  rapidity  of  the  circulation 
(Murri).  The  fever  which  follows  phlebotomy  and  the  administration 
of  cocaine  is,  according  to  Mosso,  also  dependent  upon  the  nervous 
system.  Though  recent  investigations  have  made  the  etiology  of 
wound  fever  so  plain  to  us,  we  unfortunately  are  still  much  in  the 
dark  as  regards  the  nature  of  the  febrile  process.  The  symptoms  of 
fever  are  perfectly  simple,  but  their  explanation  still  presents  many 
insurmountable  difficulties,  and  allows  plenty  of  room  for  many 
hypotheses. 

We  shall  confine  ourselves  to  the  discussion  of  the  fever  which 
accompanies  surgical  diseases. 

Symptoms  of  Fever. — The  most  important  manifestations  of  any 
fever  are  (1)  the  increase  in  the  temperature  of  the  body,  (2)  the  cir- 
culatory disturbances,  and  (3)  changes  in  the  metabolism  of  the  body. 

The  Increase  in  the  Temperature  of  the  Body. — The  most  constant 
symptom  of  fever,  and  the  one  which  is  proportionate  to  its  intensity, 
is  the  increase  in  specific  heat.     For  ascertaining  the  temperature  of 


§  62.]    REACTION  WHICH  FOLLOWS  INJURY  AND  INFLAMMATION.    307 

the  body,  we  use  in  Germany  a  thermometer  having  a  scale  divided 
into  one  hundred  parts,  and  each  of  the  one  hundred  parts  subdivided 
into  ten  parts.  The  most  useful  is  the  so-called  maximum  thermom- 
eter, in  which  the  column  of  mercury  maintains  its  altitude  after  the 
instrument  has  been  removed  from  the  axilla  or  rectum,  and  readily 
permits  at  any  time  the  reading  oil  of  the  highest  temperature  regis- 
tered. The  temperature  of  patients  who  have  been  injured  or  oper- 
ated upon  is  ordinarily  taken  in  the  axilla  or  rectum  two  or  three  times 
a  day — morning,  noon,  and  evening.  But  not  infrequently  it  is  im- 
portant that  it  should  be  ascertained  hourly,  or  every  two  hours,  espe- 
cially in  cases  with  high  fever,  in  which  the  height  of  the  fever  decides 
the  kind  of  therapeutic  measures  that  should  be  undertaken. 

If  the  fever  is  slight  the  temperature  in  the  axilla  may  amount  to 
38.5°  to  39°  C.  (101.3°  to  102°  F.) ;  if  severe,  to  40°  C.  (104°  F.) ; 
while  temperatures  above  41°  C.  (104.1°  F.)  or  42°  C.  (106.5°  F.)  are 
called  by  Wunderlich  hyperpyretic.  Unusual  rises  of  temjDerature 
like  this,  to  42°  C.  (106.5°  F.)  and  higher,  are  ordinarily  the  precursors 
of  a  rapidly  approaching  death.  Temperatures  higher  than  44.5°  C. 
(113°  F.)  are  very  rarely  observed,  though  Phillipson  has  recorded  the 
case  of  a  girl  twenty-five  years  old  in  whom  the  temperature  reached 
47.2°  C.  (116.6°  F.).  Occasionally  the  temperature  continues  rising 
several  hours  after  the  death  of  the  patient  (post-mortem  rise  of  tem- 
perature). The  initial  stage  of  fever  is  usually  characterised  by  a  more 
or  less  pronounced  feeling  of  chilliness  or  a  rigour.  This  is  the  more 
pronounced  the  more  rapidly  the  fever  rises  and  the  shorter  the  initial 
stage  of  the  fever.  A  chill  is  usually  absent  if  the  body  temperature 
rises  gradually  during  several  days.  During  the  cold  stage  the  tem- 
perature of  the  body  is  already  elevated.  The  cold  feeling  is  the 
expression  of  a  nervous  excitation  caused  by  the  difference  in  tem- 
perature existing  between  the  internal  and  the  external  or  superficial 
portions  of  the  body.  After  the  stage  of  cold  there  follows  the  climax 
— i.  e.,  the  fever  reaches  its  maximum  point.  The  subsequent  course  of 
the  fever  varies.  The  temperature  either  remains  more  or  less  con- 
tinuously elevated  (continuous  i'ever,  Fig.  289),  or  it  fluctuates  (remit- 
tent fever.  Fig.  290).  If  the  fever  is  a  continuous  one,  the  difference 
between  the  maximum  and  minimum  temperature  taken  in  the  course 
of  the  day,  or  morning  and  evening,  will  be  at  the  most  but  a  few 
tenths  of  a  degree  (Fig.  289).  In  a  remittent  fever  there  will  be  a 
daily  fall  of  about  1°  C.  (1.8°  F.)  or  more.  A  third  type  of  fever  is 
the  intermittent,  in  which  brief  marked  rises  in  temperature  alternate 
with  normal  or  even  subnormal  temperatures  (Fig.  291).  After  each 
fall  the  temperature  rises  again  in  the  course  of  the  day,  regularly 


308 


INFLAMMATION  AND  INJURIES. 


regi^teriiig  Ligher  in  the  evening  than  in  tlie  niurning,  or  the  exacer- 
bations may  occur  less  frequently  than  this.  As  we  shall  see  when  we 
come  to  diseases  of  wounds,  the  course  of  the  fever  is  typical  for  many 


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diseases,  especially  the  way  that  defervescence  takes  place.  The  decline 
of  the  temperature  may  take  place  rapidly  in  the  form  of  a  crisis,  fall- 
ing 2°  to  3°  to  4°  C.  (3.6°  to  7.2°  F.),  and  even  more  in  a  few  hours  on 
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day  on. 


normal  and  become  subnormal,  sometimes  accompanied  by  symptoms 
of  collapse  and  nervous  excitement  (delirium  of  collapse).  In  other 
cases  the  defervescence  comes  on  more  gradually  (by  lysis),  being  for 


§  63.]    REACTION  WHICH  FOLLOWS  INJURY  AND  INFLAMMATION.    309 

several  days  continuous  or  remittent,  with  transient  rises  (Fig.  290). 
The  defervescence  is  usually  accompanied  by  sweating.  After  the  fall 
in  the  fever  there  ensues  the  stage  of  convalescence,  which  is  fre- 
quently only  simulated,  as  a  new  outbreak  of  the  fever  may  take 
place  with  a  set  of  symptoms  exactly  the  same  as  those  which  occurred 
in  the  beginning  (Fig.  291).  Thus,  in  a  protracted  fever  like  chronic 
pyaemia,  the  fever  may  alternate  with  an  apparent  period  of  convales- 
cence, until  death  or  true  convalescence  make  its  appearance.  When 
the  fever  has  a  fatal  termination,  death  may  come  on  during  the  hot 
stage,  and  is  then  often  the  direct  result  of  the  high  temperature  ;  or 
the  cause  of  death  is  to  be  sought  for  in  the  general  weakening  of  the 
body  brought  about  by  the  fever,  particularly  in  the  degeneration  of 


Puis 

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Fig.  291. — Intermittent  type  of  fever  with  temporary  sudden  fall  of  temperature  (crisis)  on  the 
lifth  day ;  fresh  rise  of  temperature  on  the  seventh  day,  and  then  on  the  tenth  day  a  sudden 
fall  of  temperature  followed  by  convalescence. 


the  mnselesof  the  heart  and  the  muscular  coat  of  the  blood-vessels,  and, 
above  all,  in  the  general  systemic  poisoning  which  is  due  to  bacteria. 
The  behaviour  of  the  temperature  curve  is  a  most  important  diagnostic 
guide  for  the  surgeon  in  his  estimation  of  the  condition  of  the  reparative 
process  going  on  in  the  wound,  and  it  enables  him  to  judge  whether 
the  dressing  requires  changing  or  not.  Moreover,  the  surgical  wound 
diseases,  as  we  shall  see,  are  characterised  by  a  typical  fever  curve. 

From  these  facts  it  is  easy  to  understand  the  importance  of  care- 
fully ascertaining  the  body  heat  in  those  who  have  been  operated  upon 
or  injured. 

The  other  symptoms  of  fever  consist  of  disturbances  of  the  circula- 
tion, the  breathing,  the  digestion,  and  the  nervous  system.  They  occur 
as  the  result  of  the  elevated  temperature  or  of  the  primary  disease. 


310 


INFLAMMATION  AND   INJURIES. 


Fig.  292. — 1,  iSormal  pulse  with  well-marked  arterial  tension;  2, 
rapid,  dicrotic  puUe  in  fever ;  3.  very  rapid  dicrotic  pulse  after 
injectiou  of  atropine  (Meuriot-Marey). 


Behaviour  of  the  Pulse  in  Fever. — Great  iinj^ortanee  attaches  to  the 
coudition  of  the  pulse,  as  regards  its  frequency,  tension,  and  regularity. 
Its  frequency,  in  general,  corresponds  to  the  height  of  the  fever,  but 
exceptions  to  this  rule  are  not  infrequent ;  thus,  for  example,  as  the 
result  of  stimulating  the  vagus  or  its  centre  in  the  medulla,  there 

occurs  a  slowing  of 
the  pulse  with  an 
elevation  of  the 
temperature.  In 
cases  of  iodoform 
poisoning  the  tem- 
perature may  be 
3S°  G.  (100.4°  F.)^ 
while  the  pulse  is 
very  markedly  ac- 
celerated. The 
state  of  the  blood 
pressure  is  not  con- 
stant in  fever;  ordinarily  it  is  somewhat  lower  than  normal  (Ludwigj 
Hiiter).  If  the  fever  remains  high  for  any  great  length  of  time,  the 
blood  pressure  becomes  very  decidedly  lessened,  and  may  give  rise  to 
dangerous  symptoms.  The  pulse  is  often  dicrotic  (Fig.  292,  2) — i.  e.,  it 
shows  in  the  place  of  a  single  beat  a  double  one,  caused  by  a  diminution 
of  the  arterial  tension.  A  dicrotic  pulse  can  be  produced  artificially  in 
animals  by  injection  of  atropine  subcutaueously  or  by  administering 
amyl  nitrite  by  inhalation  (Fig.  292,  3).  The  rapidity  M'ith  which  the 
blood  current  flows,  according  to  the  measurements  taken  by  Ludwig  and 
Hiiter  with  the  sphygmograph,  is  reduced  during  fever  about  one  third. 

Condition  of  the  Vessels  during  Fever.— Maragliano  has  demonstrated, 
with  the  aid  of  Mosso's  plethysmograph,  that  the  cutaneous  blood-vessels  are 
contracted  during  fever  before  any  rise  in  temperature  can  be  detected  ;  that, 
as  the  contraction  of  the  vessels  advances,  the  temperature  begins  to  rise,  and 
reaches  its  highest  altitude  simultaneously  with  the  maximum  of  contraction 
in  the  vessels ;  and  that  the  fall  of  temperature  is  preceded  bj^  a  dilatation  of 
the  blood-vessels. 

Cheilo-angioscopy. — Hiiter  has  attempted  to  make  a  microscopic  investiga- 
tion of  the  circulation  of  the  blood  in  the  lip  of  a  man  suffering  from  fever. 
The  cheilo-angioscope,  as  it  is  called,  which  is  used  for  this  purpose,  is  de- 
scribed in  Part  I  of  Hitter's  Principles  of  Surgery.  By  means  of  this  instru- 
ment he  noted  that  in  fever  the  circulation  in  the  smaller  vessels  was  retarded, 
and  finally  that  the  blood  in  them'  came  to  a  standstill. 

Condition  of  the  Respiration  during  Fever.  — During  fever  the  respi- 
ration is  more  active ;  there  is  a  greater  consumption  of  oxygen,  and 


§  62.]    REACTION  WHICH  FOLLOWS  IXJIJRY  A^^D  mFLAMMATION.    311 

as  fever  increases,  or,  in  other  words,  metabolism  becomes  more  active, 
there  is  a  larger  amount  of  carbonic  acid  produced.  According  to 
Kraus,  twenty  per  cent,  more  oxygen  is  consumed  during  fever  than 
when  the  body  is  in  a  normal  condition.  The  respiration,  particularly 
at  the  beginning  of  the  fever,  is  deeper  than  it  ordinarily  is  ;  but  later 
on,  after  the  fever  has  jDersisted  some  time,  it  becomes  shallower,  on 
account  of  the  weakening  of  the  respiratory  muscles.  If  the  fever 
lasts  for  a  long  time,  an  increase  in  the  amount  of  gaseous  interchange 
in  the  lungs  may  not  take  place,  owing  to  the  accompanying  inanition 
of  the  patient. 

Disturbances  of  the  Nervous  System. — The  disturbances  of  the  nerv- 
ous system  during  fever  vary  with  the  height  to  which  the  temperature 
rises,  and  with  the  location  of  the  injury.  They  consist  in  a  feeling  of 
general  lassitude  and  debility,  and,  if  the  fever  is  high,  in  a  dulling  of 
the  patient's  intellect,  accompanied  by  all  kinds  of  symptoms  denoting 
irritation  and  depression  of  the  central  nervous  system. 

Digestion. — The  digestion  is  impaired  during  fever ;  there  is  pro- 
nounced loss  of  appetite ;  there  is  a  diminution  in  the  amount  of  the 
digestive  juices  secreted,  and  the  peristalsis  of  the  gastro-intestinal 
canal  is  lessened.  Thirst  is  usually  increased,  and  the  tongue  is  apt 
to  be  dry. 

Urine. — The  amount  of  urine  secreted  is  diminished,  chiefly  as  the 
result  of  the  lessened  absorption  of  nutritive  matter  and  the  increased 
excretion  of  water  by  the  skin  and  lungs.  The  urine  of  a  patient  in 
fever  has  a  high  specific  gravitj^  ;  it  is  rich  in  nitrogenous  substances, 
particularly  urea,  and  in  the  calcium  salts,  and  it  is  poor  in  sodium 
chloride.  The  large  percentage  of  calcium  salts  and  colouring  matter 
is  due  to  the  increased  disintegration  of  the  red  blood-corpuscles  which 
takes  place  during  fever,  l^fot  infrequently  the  urine  in  fever  con- 
tains albumen  and  hyaline  casts. 

Muscular  System. — The  symj)toms  referable  to  the  muscular  system^ 
consisting  of  weakness  and  pain,  are  partly  nervous  in  their  nature, 
l^eing  caused,  in  all  probability,  by  an  altered  innervation,  and  partly 
are  directly  dependent  upon  changes  in  the  muscles  consisting  of  a 
parenchymatous  degeneration  of  their  contractile  substance. 

Body  Weight. — The  weight  of  the  body  diminishes  during  fever,  as 
a  result  of  the  increased  metabolism  or  destruction  of  albumen.  The 
weight  which  a  patient  loses  in  fever  would  be  much  greater  if  the 
destruction  of  fat  were  in  the  same  ratio  as  that  of  albumen.  Accord- 
ing to  Kraus,  the  fat  is  not  destroyed  in  the  same  proportion  as  the 
albumen.  Leyden  has  demonstrated  by  many  systematic  measurements 
that  the  loss  of  weight  is  greatest  during  the  crisis  of  the  fever,  and  in 


312  INFLAMMATION   AND   INJURIES. 

twentv-four  hours  at  this  stage  the  average  weight  lost  amounts  to  10.6 
parts  iu  1,000. 

Prognosis — Outcome  of  the  Fever. — As  Cohnheim  has  correctly  stated, 
the  body  makes  use  of  fever  to  destroy  as  rapidly  as  possible  the  noxious  sub- 
stances which  have  gained  access  to  it.  In  this  sense  fever  is  advantageous 
to  the  organism.  It  was  formerly  thought  that  the  danger  in  a  febrile  dis- 
ease lay  mainly  in  the  elevation  of  the  temperature — in  other  words,  that 
death  was  caused  pi'incipally  by  the  abnormally  great  specific  heat.  This 
view  is  being  more  and  more  successfully  contested.  We  know  now.  as 
regards  the  febrile  diseases,  especially  those  following  wounds,  that  the 
species  of  pathogenic  bacteria  which  may  be  present,  or  the  products  of  their 
metabolism,  are  the  principal  factors  in  determining  the  prognosis  of  the 
febrile  infection.  The  length  of  time  which  a  febi'ile  disease  lasts  may,  aside 
from  the  severity  and  nature  of  the  infection,  become  dangerous  to  the  patient 
as  a  result  of  the  increasing  inanition.  According  to  Leyden,  the  daily  loss 
during  fever  amounts  to  about  seven  tenths  per  cent,  of  the  total  weight. 
Chossat  states  that  all  the  higher  animals  die  when  they  have  lost  forty  per 
cent,  of  their  weight  tlu'ough  deprivation  of  nourishment :  consequently 
a  moderately  severe  fever  would  be  sufficient  to  kill  a  man  in  about 
eight  weeks. 

The  Pathological  Changes  during  Fever.— The  pathological  changes  in 
fever  will  be  described  under  the  infectious-wound  diseases,  and  when  we 
come  to  discuss  those  subjects  we  shall  learn  about  the  changes  in  the  com- 
position of  the  blood  brought  about  by  micro-organisms.  It  is  sufficient  to 
note  here  that  the  cloudy  swelling,  or  pai-enchymatous  degeneration,  as  it  is 
called,  of  the  glands  and  muscles,  varying  fi'om  a  granular  cloudiness  and 
swelling  to  pronounced  fatty  degeneration,  used  to  be  erroneously  looked 
upon  as  the  result  of  the  high  temperature.  Furthermore,  the  loss  of  weight 
which  accompanies  a  fever  of  any  considerable  duration  is  not  the  du'ect 
result  of  the  fever,  but  of  the  infection  or  intoxication  which  has  occurred. 
It  is  more  exact  to  ascribe  all  these  changes  not  to  the  increased  heat  of  the 
body,  but  to  the  natui'e  of  the  infection  or  poisoning. 

Etiology  and  Nature  of  Fever,  particularly  of  Wound  Fever. — If  we 
would  understand  the  etiology  and  nature  of  fever,  we  must  attempt 
to  give  an  explanation  of  the  principal  symptom  of  fever — viz.,  the 
rise  of  temperature.  TTe  have  already  emphasised  the  fact  that  fever 
is  mainly^ the  result  of  absorption,  Billroth  and  C.  O.  "Weber  were 
the  first  to  add  materially  to  our  knowledge  of  the  etiology  of  fever, 
and  they  demonstrated  that  fever  can  be  caused  in  animals  by  intro- 
ducing into  the  subcutaneous  cellular  tissue,  or  directly  into  the  Idood,. 
decomposing  animal  or  vegetable  matter.  But  not  only  are  actually 
decomposing  and  putrid  substances  capable  of  cau.sing  fever — i.  e., 
pvrogenous — but  also  every  kind  of  pus  due  to  bacterial  infection, 
including  the  so-called  pus  honiim  et  laudalnle^  has  the  same  pyroge- 
nous  effect.     The  micro-organisms  (the  bacteria)  are  the  most  impor- 


§  62.]   REACTION  WHICH  FOLLOWS  IXJURY  AND  IXFLAM3IATI0X.    313 

tant  of  the  causes  of  fever,  giving  rise  to  it  as  soon  as  thej,  or  the  dis- 
solved poisonous  products  of  their  metabolism  (toxines),  gain  access 
to  the  circulation  (see  §  59).  The  bacteria  act  bv  decomposing  their 
nutritive  media,  consisting  of  the  animal  tissues,  the  blood,  and  the 
lymph,  giving  rise  to  fermentative  and  decomposition  processes,  and 
destroying  the  blood-corpuscles,  particularly  the  white  ones,  etc.  TTe 
learned  in  §  59  that  the  poisonous  products  of  their  metabolism  vrliich 
have  been  isolated  from  the  bacteria  are  also  capable  of  exciting  a  gen- 
eral febrile  intoxication.  ^lention  should  also  be  made  of  the  rise  of 
temperature  occurring  in  conjunction  "vvith  constipation,  particiilarlv 
that  following  an  operation,  for  instance.  This  fever  is  probably  due 
to  the  absorption  of  soluble  decomposing  substances  which  are  formed 
either  with  or  without  the  co-operation  of  bacteria.  Every  intoxication. 
fever  is  not  by  any  means  to  be  ascribed  to  bacteria,  as  we  know  that 
substances  capable  of  exciting  fever,  such  as  ferments,  can  be  formed 
in  extravasated  blood  and  in  the  undecoraposed  secretion  of  a  wound, 
without  the  co-operation  of  bacteria.  "We  are  already  familiar  with 
several  ferments  of  this  kind  which  have  the  power  of  producing 
fever,  notably  the  fibrin  ferment  (Alexander  Schmidt),  which  causes  a 
rise  of  temperature  to  take  place  in  the  animal  into  which  blood  has 
been  transfused,  particularly  when  the  blood  is  taken  from  an  animal 
of  another  species.  Hammerschlag  examined  the  blood  of  fifteen  pa- 
tients during  fever,  and  found  fibrin  ferment  existing  in  a  free  state  in 
the  blood  of  twelve.  He  also  found  it  free  in  the  blood  of  two  patients 
who  did  not  have  fever.  The  presence  of  the  fibrin  ferment  in  the 
blood  during  fever  is  not  constant,  consequently  no  satisfactory  theory 
of  fever  based  upon  the  fibrin  ferment  can  be  established.  In  fact, 
Schmitzler  and  Ewald  have  of  late  denied  that  the  fibrin  ferment 
formed  in  subcutaneous  extravasation  of  blood  can  cause  fever.  They 
claim  that  the  nucleins  and  albumoses  that  develop  in  these  collections 
of  blood  are  the  causes  of  the  so-called  aseptic  fever.  Other  investi- 
gators have  also  shown  that  albumoses  of  different  derivations  cause 
fever.  Solutions  of  haemoglobin  also  have  a  pyrogenous  action — i.  e.. 
they  are  capable  of  exciting  fever.  Schmiedeberg  has  isolated  from 
the  blood  another  ferment,  histocym,  and  has  demonstrated  that  this 
body,  which  is  a  product  of  the  normal  metabolism,  when  introduced 
into  the  circulation  in  sufiicient  quantities  can  give  rise  to  high  fever. 
Bergmann  and  Angerer  have  shown  that  other  ferments,  such  as  pep- 
sine,  pancreatine,  etc.,  have  the  same  power. 

This  non-bacterial  ferment  fever,  as  we  may  call  it,  is  observed  after 
subcutaneous  injuries  of  bones  and  soft  parts  which  are  accompanied 
by  considerable  extravasation  of  blood.    This  is  the  explanation  of  a  rise 


3U  INFLAMMATION   AND   INJURIES. 

in  temperature,  wliicli  may  reach  39°  to  40°  C.  (102.2°  to  104°  F.), 
and  wliicli  makes  its  appearance  after  a  subcutaneous  fracture,  a  severe 
contusion  of  a  joint,  or  a  subcutaneous  injury  of  soft  parts.  In  the 
same  category  belongs,  perhaps,  the  fever  following  absorption  of  the 
imdecomposed  primary  secretion  of  a  wound,  called  aseptic-wound 
fever,  and  which  may  cause  the  temperature  to  rise  as  high  as  40°  C. 
(104°  F.),  even  when  the  repair  of  the  wound  runs  a  perfectly  aseptic 
course  (Yolkmann  and  Geiizmer).  ZS^evertheless,  I  beheve,  at  present, 
that  this  aseptic-wound  fever  is  often  the  result  of  a  too  free  use  of 
antiseptics  during  the  operation.  If  the  wound  is  much  irritated, 
especially  by  such  an  antiseptic  as  carbolic  acid,  there  will  follow,  not 
infrequently,  extravasations  of  blood  into  the  wound,  there  will  be  a 
considerable  amount  of  secretion,  and  the  above-mentioned  ferments 
will  develop  in  the  stagnant  blood,  and,  even  though  the  wound 
remains  aseptic,  these  ferments  will  give  rise  to  the  so-called  aseptic- 
wound  fever.  Since  I  began  to  avoid  the  poisonous  antiseptics  in 
aseptic  operations  I  have  not  observed  this  aseptic-wound  fever  nearly 
so  often.  In  my  opinion  this  aseptic-wound  fever  can  be  explained  in 
different  ways — either  as  a  reflex  manifestation,  or  as  an  absorption 
fever  due  to  the  absorption  of  certain  pyrogenous  products  (toxines). 
The  latter  are  chiefly  organic  substances  resulting  from  the  physio- 
logical metabolism  of  the  body.  Bacterial  toxines  probably  also  play  a 
part  in  some  cases. 

Chronic  Ferment  Intoxication.— Langenbeck  and  Cramer  have  recorded 
an  interesting  case  of  chronic  ferment  intoxication  with  continuous  liigh 
fever,  cough,  and  occasional  diarrhoea  in  a  young  woman  who  had  a  blood 
cyst  the  size  of  a  goose-egg  on  the  thigh.  The  blood  cyst  had  probably*  de- 
veloped from  a  pre-existing  cavernous  angioma.  After  its  operative  removal 
all  disagreeable  symptoms  immediately  vanished.  Within  the  cyst,  as  in  all 
blood  which  is  not  in  contact  with  the  normal  walls  of  the  vessels,  or  which 
becomes  stagnant,  there  had  developed  different  ferments,  among  them 
Schmidt's  fibrin  ferment,  which  had  then  gained  access  to  tlie  general  circu- 
lation, as  the  cyst,  from  the  cavernous  structure  of  its  walls,  was  in  direct 
communication  with  the  vascular  system.  The  febrile  symptoms,  and  the 
coagulation  processes  in  the  capillaries  of  the  lungs  and  intestines,  were 
caused  in  this  way,  corresponding  in  every  respect  to  the  facts  Avhich  had 
been  noted  by  Kohler,  Bergmann,  and  others  in  their  experiments  on  ferment 
intoxication. 

We  are  able,  then,  to  distinguish  two  classes  of  absorption  fever, 
the  first  being  the  fever  caused  by  micro-organisms  and  the  poisonous 
products  of  their  metabolism  (ptomaines,  toxines)  which  have  gained 
access  to  the  circulation,  and  the  second  being  the  fever  which  follows 
the  absorption  of  the  disintegrated  products  of  the  body,  these  products 


§62.]    REACTION  WHICH  FOLLOWS  INJURY  AND  INFLAMMATION.    315 

differing  but  little  from  the  substances  formed  in  the  physiological 
metabolism  of  the  body  (non-bacterial  ferment  fever).  These  are  un- 
doubtedly fever-producing  substances  whose  chemical  nature  we  can  at 
present  not  exactly  determine. 

The  part  played  by  the  nervous  system  in  the  production  of  any 
one  of  the  various  kinds  of  fevers  is  briefly  spoken  of  on  page  306. 

Explanation  of  the  Febrile  Process.— How  do  these  fever-producing-  suij- 
stances,  the  bacteria  and  the  products  of  their  metabolism,  the  non-bacterial 
ferments,  the  albumoses,  nucleins,  etc.,  and  the  central  nervous  system,  act  ? 
In  other  words,  in  what  way  does  the  principal  symptom  of  fever,  the  rise 
in  temperature,  come  about  ?  It  is  well  known  that  the  body  temperature 
normally  regulates  itself  within  moderate  fluctuations,  and  that  the  amount 
of  heat  formed  and  lost  occasionally  changes  even  in  health — it  increases 
and  diminishes.  The  amount  of  heat  g-iven  off  by  the  body  is  influenced 
by  the  clothing  or  coverings  of  the  body,  by  the  persjiiration,  by  the  circu- 
lation of  blood  in  the  skin,  and,  finally,  by  the  increased  or  diminished 
excretion  of  warmth  and  moisture  through  the  lungs.  The  amount  of  heat 
developed  is  altered  by  the  voluntary  or  involuntary  increase  of  muscular 
activity,  by  the  processes  going  on  in  the  glands  and  tissues,  by  the  inges- 
tion of  nutritive  material,  or,  in  other  words,  by  the  increased  or  dimin- 
ished supj)ly  of  fuel.  The  nervous  system,  through  its  reflexes,  regulates 
these  various  portions  of  the  aj)paratus,  causing  each  to  assume  its  projoer 
activity,  and  thus  is  explained  the  constancy  of  the  temperature  of  the  body. 

During  fever  the  amount  of  heat  produced  is,  in  the  first  place,  increased, 
and  the  substances  which  excite  fever  must  somehow  afiFect  those  parts  of  the 
body  which  regulate  the  production  of  heat.  We  are  ignorant  of  the  exact 
manner  in  which  this  takes  place  during  the  febrile  process.  We  can  only 
say  that  the  physiological  warmth  of  the  body  is  the  product  of  the  biochem- 
ical metabolism  of  the  tissues,  and  the  febrile  agent  causes  an  increased  meta- 
bolism, and  consequently  an  increased  production  of  heat.  It  can  be  proved 
that  the  metabolism  or  combustion  is  actually  increased  during  fever.  The 
increased  consumption  of  oxygen,  the  increased  excretion  of  carbonic  acid 
and  nitrogenous  substances,  particularly  urea,  are  all  evidences  of  the  truth 
of  this.  The  increase  in  urea  corresponds  in  general  to  the  severity  of  the 
fever,  and,  according  to  Cohnheim,  no  matter  how  little  food  is  administered, 
there  may  be  three  times  more  urea  excreted  than  normally,  and  it  may 
amount  to  forty  to  fifty  grammes  per  diem.  This  increased  secretion  of  urea 
means  that  a  greater  disintegration  of  albumen  is  taking  place  within  the 
body.  Leyden  gives  the  excretion  of  carbonic  acid  as  one  and  a  half  to  two 
and  a  half  times  more  than  in  a  state  of  health. 

Are  there  certain  tissues  in  which  the  increased  production  of  heat  is  more 
marked  than  in  others  ?  This  question  has  not  as  yet  been  answered.  We 
only  know  that  muscular  tissue,  particularly  that  of  the  heart,  nerve  tissue, 
anci  the  glands,  are  important  factors  in  the  generation  of  heat.  Mosso  was 
unable  to  demonstrate  in  the  cortex  of  a  dog's  brain  any  circumscribed  cen- 
tre i^egulating  the  heat  of  the  body,  bvxt  he  conjectured  that  the  regulating 
power  was  widely  distributed  throughout  the  brain  and  spinal  cord.     Aron- 


316  INFLAMMATION  AND  INJURIES. 

son,  Sachs,  and  Gottlieb  affii'ui  that  the  heat  centre  for  rabbits  exists  iu  the 
corpus  striatum. 

The  blood  is  certainly  one  of  the  most  important  sources  of  the  rise  of 
temperature  in  fever,  and  this  is  particularly  true  in  wountl  fevers,  where  it 
contains  bacteria  and  the  dissolvetl  poisonous  products  of  their  metabolism. 
By  the  latter's  presence  in  tlie  circulation  we  know  that  the  blood  becomes 
altered  and  that  the  white  blood-corpuscles  are  destroyed.  It  is  probable 
that  the  increased  metabolism  and  the  rise  of  temperature  are  the  results  of 
the  alteration  in  the  blood,  since  the  heart  and  tne  walls  of  the  vessels  are 
directly  affected  by  the  noxious  substances,  particularly  the  dissolved  poison- 
ous products  of  bacterial  metabolism.  Consequently  Bergmann  has  advanced 
the  view,  and  it  seems  to  me  to  be  the  correct  one,  that  the  cause  of  the  febrile 
rise  of  temperature  is  to  be  sought  for  m  an  increased  metabolism  in  the 
blood.  The  alterations  in  the  blood,  according  to  Bei'gmann,  are  the  most 
essential  of  all  the  accompaniments  of  fever.  In  order  to  retain  the  constancy 
of  the  composition  of  the  blood,  all  the  machinery  in  the  body  designed  for 
this  purpose  exhibits  a  more  intense  activity,  and  in  this  way  are  explained 
the  increased  metabolism  and  rise  in  temperature  which  occur  in  fever.  On 
account  of  the  elevated  temperature  of  the  blood  the  further  development 
and  spread  of  certain  species  of  pathogenic  bacteria  are  prevented.  It  is  a 
fact  that  in  anthrax  infection,  for  example,  the  animal  affected  has  only  to  be 
repeatedly  cooled  off  to  make  the  bacilli  ajDpear  immediately  in  the  blood. 
The  fever  or  elevation  of  the  temperature  of  the  body  and  the  gi'eater  activity 
of  its  metabolism  is  all  a  conservative  process  which  the  body  makes  use  of 
to  more  rapidly  get  rid  of  the  injurious  substances  which  have  gained 
access  to  it. 

In  other  cases,  where  there  is  no  intoxication  or  infection  of  the  blood  or 
tissues,  the  rise  in  temperature  is  due  to  influences  connected  with  the  nerv- 
ous system,  as  we  have  before  remarked. 

Loss  of  Heat  during  Fever.— What  are  the  conditions  as  regards  the 
amount  of  heat  lost  during  fever  ?  Ordinarily  the  amount  of  heat  lost  dur- 
ing the  chill  is  less  than  normal,  but  during  the  height  of  the  fever,  ac- 
cording to  Leyden's  measurements,  it  is  greater,  being  for  tempei^atures  above 
40°  C.  (104°  F.)  double  the  normal,  and  even  triple  when  there  is  an  abun- 
dant secretion  of  sweat.  Nevertheless  the  body  is  unable  to  get  rid  of  its 
excess  of  warmth,  because  the  amount  of  heat  produced  is  continuously 
increased  during  fever,  while  the  amount  lost  fluctuates,  at  one  time  being 
greater  than  normal  and  at  another  less.  The  diminution  in  the  amount  of 
heat  lost  is  due  to  the  contraction  of  the  cutaneous  blood-vessels,  which,  as 
we  saw  on  page  307.  begins  before  the  rise  in  temperature. 

Traube,  particularly,  taught  that  the  cause  of  fever  was  to  be  found  in 
the  diminished  amount  of  heat  lost,  or  rather  in  the  pathological  changes 
connected  with  the  loss  of  heat.  It  is  more  correct  to  ascribe  the  cause  of 
fever  to  the  increased  production  of  heat  resulting  from  the  more  active 
metabolism,  in  conjunction  with  a  pathological  alteration  in  the  amount  of 
heat  lost.  The  amount  of  heat  lost  is  not  constant,  as  Traube  thought,  but 
it  is  pathologically  altered,  being  at  one  moment  increased  and  at  another 
decreased.  Traube  was  wrong  in  denying  an  increased  production  of  heat 
in.  fever. 


§62.]    REACTION  WHICH  FOLLOWS  INJURY  AND  INFLAMMATION.    8I7 

Definition  of  the  Febrile  Process.— If  we  should  wish  to  formulate  a 
definition  of  the  febrile  process,  we  can  say,  with  liecklinghausen 
that  fever  is  a  disturbance  which  increases  the  metabolism  of  the 
materials  of  the  bodj,  especially  the  tissues  which  are  rich  in  albu- 
minous substances.  This  increased  metabolism  may  have  its  cause  in 
the  nervous  system  or  in  the  blood.  Recklinghausen  considers  that 
the  part  of  the  system  principally  aiiected  by  fever  is  the  motor  appa- 
ratus of  the  vascular  system,  consisting  of  the  heart  and  muscular  coat 
of  the  vessels  which  are  regulated  by  the  vasomotor  nervous  system. 
The  latter  plays,  according  to  Recklinghausen,  one  of  the  most  impor- 
tant parts  in  the  production  of  fever.  The  typical  symptoms  of  fever 
result  from  a  combination  of  excitation  of  the  nervous  and  vasomotor 
apparatus,  with  an  increase  in  the  biochemical  processes  carried  on  by 
the  tissues  of  the  body,  due  to  certain  causes.  The  exciting  cause  of 
the  fever  leads  to  molecular  changes  in  the  body  substances,  but  how 
this  comes  about  still  bafiles  us. 

Treatment  of  Fever. — We  shall  confine  ourselves  to  the  treatment  of 
wound  fever.  It  is  mainly  surgical,  and  consists,  in  the  first  place,  in 
properly  treating  the  existing  injury.  The  best  prophylactic  measures 
in  the  treatment  of  wound  fever  consist  in  carrying  out  strictly  the 
rules  of  antisepsis  and  asepsis.  It  is  very  important  to  provide  for  the 
escape  of  secretions  from  the  wound  by  means  of  careful  drainage.  If 
fever  makes  its  appearance  in  a  patient  who  has  been  wounded  or  op- 
erated upon,  it  is  advisable  to  examine  the  wound  carefully  to  deter- 
mine whether  there  is  a  retention  of  the  secretion  or  some  other  ab- 
normity. In  wounds  which  have  been  sutured,  which  involve  the  scalp, 
for  instance,  it  may  be  sufiicient  to  remove  the  sutures  and  pei'mit  a 
free  escape  of  the  retained  secretion,  and  the  fever  will  thus  often  dis- 
appear very  promptly.  In  other  cases  deep  incisions  may  have  to  be 
made  on  account  of  the  retention  of  secretions,  and  abundant  drainage 
may  be  necessary.  I  make  it  a  rule  to  change  the  dressings  on  patients 
who  have  been  injured  or  operated  upon  if  the  temperature  rises  above 
38.5°  C.  (101.3°  F.).  If  the  wound  is  really  aseptic,  as  in  fresh  in- 
juries, or  after  operations,  healing  without  fever  is  usually  assured. 
The  different  wound  diseases  due  to  infection  must  receive  their  special 
treatment  Csee  §§  66-82).  If  the  temperature  becomes  too  much  ele- 
vated, or  if  the  duration  of  the  fever  threatens  to  cause  serious  weakness 
of  the  patient,  in  addition  to  the  above  briefly  outlined  local  treatment 
of  the  wound,  it  is  advisable  to  adopt  other  suitable  means  of  treating 
the  fever,  just  as  in  ordinary  febrile  diseases.  The  best  way  of  reducing 
the  temperature  when  there  is  no  contraindication  consists  in  the  em 
ployment  of  cool  baths,  cold  packs,  and  sponging  off  with  cold  water. 


318  INFLAMMATION  AND  INJURIES. 

The  cold-water  treatment  of  fever  is  considered  by  many  physicians 
the  best  means  at  our  disposal  for  reducinjj  the  temperature.  It  is  used 
either  in  the  form  of  baths  at  a  temperature  of  20°  C.  (68°  F.),  in 
which  the  patient  is  immersed  for  ten  minutes,  or  baths  at  a  tempera- 
ture of  24°  C.  (75.2°  F.),  which  are  gradually  cooled  down  during 
fifteen  to  twenty  minutes  to  a  temperature  of  22°  C.  (71.8°  F.).  At 
the  same  time,  in  proper  cases  cold  water  is  poured  over  the  patient, 
or  even  ice  water,  as  he  lies  in  the  tub.  This  serves  as  an  excellent 
stimulant  to  respiration  and  the  psychical  functions.  The  patient  is 
then  brought  back  to  bed  without  being  previously  dried  olf,  as  in 
this  way  the  cooling  off  ^vill  continue  longer.  Wine  should  be  admin- 
istered freely  as  a  stimulant  while  the  patient  is  being  subjected  to 
this  treatment.  The  reduction  of  temperature  by  medicaments,  such 
as  quinine,  digitalis,  veratrum  viride,  sodium  salicylate,  antipyrine,  etc., 
should  be  employed  when  the  patient  cannot  stand  cold  baths,  or  when, 
for  some  reason  or  other,  their  use  is  not  practicable. 

The  action  of  the  antipyretic  drugs,  such  as  antipyrine,  has  been 
repeatedly  tested  in  recent  times,  and  it  has  been  proved  that  they  act 
principally  through  the  nervous  system,  particularly  the  vasomotor  part 
of  it,  and  the  heat  centres  in  the  brain  ;  they  increase  the  amount  of  heat 
lost,  or  they  diminish  the  amount  of  heat  produced,  or  they  do  both. 
Maragliano  demonstrated  that  kairine,  antipyrine,  thalline,  quinine,  and 
salicylate  of  sodium,  whether  administered  during  fever  or  in  health, 
caused  dilatation  of  the  cutaneous  vessels,  and  thus  increased  the 
amount  of  heat  lost  by  radiation. 

The  pulse  must  be  carefully  watched,  and,  if  necessary,  the  heart's 
action  stimulated  by  drugs  (camphor,  digitalis,  caffeine,  whiskey,  etc.). 
These  are  to  be  given  early  in  all  those  febrile  infectious  diseases  which 
tend  to  weaken  the  heart,  such  as  diphtheria. 

The  best  treatment  by  the  surgeon  of  wound  fever  consists  in  a 
careful  investigation  of  the  wound,  and,  as  far  as  possible,  in  remedying 
any  abnormity  which  may  exist.  The  treatment  of  the  rise  in  tem- 
perature, if  present,  is  next  to  be  considered,  though  it  will  generally 
not  be  necessary  to  do  more  than  to  rectify  any  abnormal  condition 
which  may  be  found  in  the  wound.  At  present  antipyresis — i.  e.,  the 
reduction  of  elevated  temperatures— is  not  so  energetically  carried  out 
as  it  used  to  be  even  in  medical  cases.  Lately  we  have  been  giving  up 
more  and  more  the  idea  that  the  temperature  curve  is  the  only  consid- 
eration which  determines  our  treatment  of  fevers.  Eepeated  observa- 
tions have  demonstrated  that  there  is  no  truth  in  the  idea  that  man  can- 
not survive  an  elevation  of  the  specific  heat  of  his  body  above  42°  C. 
(107.6°  F.).     Striimpell  and  others  have  declared  that  the  reduction  of 


§  63.]  SHOCK.  319 

the  increased  body  temperature  should  not  form  the  only  part  of  our 
treatment  of  fevers.  A  routine  treatment  of  fever  is  not  a  good  plan. 
Every  case  must  be  treated  symptomatically,  according  to  the  condi- 
tions which  may  arise.  Too  energetic  antipyi-esis — i.  e.,  the  adoption 
of  too  active  measures  for  reducing  temperature — can  frequently  do 
more  harm  than  good,  from  the  fact  which  we  mentioned  before, 
viz.,  that  the  temperature  of  the  body  must  be  higher  than  normal  to 
render  possible  the  sudden  or  gradual  destruction  of  many  species  of 
bacteria  ;  and  if  the  temperature  of  the  body  is  lowered,  infection  of  the 
blood  is  favoured. 

It  is  wise  to  give  patients  who  have  fever  easily  digestible  food,  and 
to  restrict  its  amount  and  variety.  Cool,  effervescing  waters  with 
citric  acid,  fruit  juices,  and  wines  should  be  allowed  as  drinks.  If  an 
individual  has  been  accustomed  to  the  use  of  alcohol,  the  latter  should 
not  be  denied  him  entirely,  as  otherwise  nervous  complications,  or 
even  delirium  tremens,  may  make  their  appearance  (see  §  64).  Fur- 
thermore, it  is  known  that  alcohol  has  the  power  of  directly  reducing 
temperature. 

§  63.  Shock. — By  shock  is  understood  a  peculiar  state  of  depression 
of  the  nervous  system,  which  is  apt  to  be  excited  reflexly  by  injuries 
involving  a  shaking  up  or  contusion  of  the  sensory  nerves. 

Etiology  of  Shock. — Fischer,  Goltz,  and  Seabrook  consider  the  es- 
sence of  shock  to  be  a  paralysis  of  the  vasomotor  centre  in  the  medulla 
oblongata,  produced  reflexly  by  a  contusion  or  violent  disturbance  of 
the  sensory  nerves  in  the  manner  illustrated  by  Goltz's  well-known 
experiment  on  the  frog.  By  repeatedly  striking  the  abdomen  of  a 
frog  there  is  produced  a  peculiar  state  of  collapse,  which  can  terminate 
fatally  by  cardiac  paralysis,  the  heart  stopping  in  diastole.  The  cause 
of  these  phenomena  lies  in  the  fact  that  by  mechanical  irritation  of 
the  intestines,  or  the  irritation  of  any  sensory  nerves,  the  activity  of 
the  brain  and,  above  all,  of  the  vasomotor  centre  in  the  medulla  ob- 
longata, become  reflexly  altered,  weakened,  or  paralysed.  As  a  result 
of  this  there  follows  a  diminution  or  paralysis  of  the  vascular  tone,  par- 
ticularly in  the  arteries.  There  is  a  weakening  in  the  propelHng  force 
driving  on  the  stream  of  blood,  the  speed  of  the  current  lessens,  and 
the  blood  pressure  dimifiishes ;  the  blood  is  unequally  distributed,  the 
arterial  system  is  less  full,  the  lungs  and  brain  are  anaemic,  while,  on 
the  other  hand,  the  blood  collects  in  the  veins,  particularly  those  of  the 
abdomen.  Eventually  the  disturbances  in  the  circulation  may  become 
so  pronounced  that  the  heart's  action  ceases.  The  inhibitory  nerves  of 
the  heart  play  a  part  only  when  the  terminal  branches  of  the  pneumo- 
gastric  nerves  are  directly  acted  upon  by  the  traumatism. 


320  INFLAMMATION  AND   INJURIES. 

Symptoms  of  Shock. — The  sjniptoius  of  sliock  in  man  correspond 
exactly  to  the  facts  which  have  been  determined  experimentally.  All 
the  manifestations  of  shock  can  be  traced  back  to  the  paralysis  of  the 
vasomotor  nerves  produced  reilexly  by  the  contusion  of  the  sensory 
nerves. 

The  characteristic  symjAoms  of  shock  are  a  marked  pallor  and 
coolness  of  the  skin  and  visible  mucous  membranes  ;  the  face  is  with- 
out expression  ;  the  eyes  are  dull  and  staring,  the  pupils  are  dilated, 
and  react  slowly.  The  heart's  action  is  plainly  delayed,  irregular,  and 
weak  ;  the  pulse  is  thready  or  imperceptible  ;  the  respiration  is  irregu- 
lar and  long ;  deep  breaths  alternate  with  shallow  inspiratory  efforts. 
The  -mind  is  dull  and  reacts  slowly  ;  the  j^atients  are  completely  apa- 
thetic, and  will  only  answer  questions  tardily  and  unwillingly.  The 
sensibility  of  the  superficial  portions  of  the  body  is  impaired,  and  the 
energy  of  muscular  movement  is  diminished.  Not  infrequently  there 
is  nausea  or  actual  vomiting.  The  temperature  is  about  1°  to  1.5°  C. 
(1.8°  to  2.Y°  F.)  below  the  normal.  In  other  cases,  instead  of  the 
above-described  torpid  form  of  shock,  there  will  be  a  more  active  set 
of  symptoms — in  other  words,  the  patients  are  more  excited,  they  iling 
themselves  about,  cry  out,  shriek,  and  act  like  maniacs. 

Shock  occasionally  changes  gradually  into  deep  syncope  and  ends 
in  death,  particularly  in  the  case  of  neuropathic,  anaemic  individuals. 
In  such  cases  there  will  usually  be  found  complicated  injuries  with 
severe  loss  of  blood,  and  the  post-mortem  examinations  will  frequently 
show  that  there  are  also  severe  internal  injuries,  perhaps,  of  the  brain. 
As  a  general  rule,  patients  suifering  from  uncomplicated  shock  will 
recover  after  the  lapse  of  a  longer  or  shorter  time,  ordinarily  after  a 
few  hours.  Sometimes  a  psychical  change  persists  for  a  certain  length 
of  time,  but  eventually  perfect  recovery  will  take  place.  All  nervous 
manifestations,  syncope,  etc.,  which  follow  severe  losses  of  blood  and 
which  may  look  very  much  like  shock,  should  be  carefully  distinguished 
from  true  shock  (see  §§  87-89). 

The  individual  symptoms  of  shock,  particularly  cerebral  shock,  will 
be  described  in  Regional  Surgery  under  Concussion  of  the  Brain. 
The  latter  injury  may  cause  the  patient  to  lose  more  or  less  completely 
all  recollection  of  the  accident.  He  may  ftot  be  able  to  remember 
how  he  was  hurt,  he  may  have  no  idea  of  distance  and  time,  and  may 
even  forget  everything  he  did,  saw,  or  heard  for  several  days  before 
the  time  of  his  injury.  As  the  circulation  in  the  brain  becomes  in 
time  gradually  restored  and  regulated,  the  patient  may  recover  some 
of  his  lost  memories,  but  a  j^art  of  his  experiences,  recollections,  and 
■conceptions  will  remain  lost  forever. 


§64.]  *  DELIRIUM  TREMENS.  321 

The  Treatment  of  Shock. — The  treatment  of  shock  consists,  in  the 
main,  in  overcoming  as  soon  as  possible  the  existing  paralysis  of  the 
vasomotor  nerves,  together  with  the  accompanying  disturbances  which 
the  paralysis  gives  rise  to.  To  combat  effectively  the  cerebral  anaemia, 
the  head  of  the  patient  should  be  placed  low  down  ;  but  if  venous  con- 
gestion of  the  face  becomes  marked  this  position  of  the  head  must  be 
immediately  given  up,  Fischer  and  Konig  are  right  in  recommend- 
ing vigorous  stimulation  of  the  skin  by  sinapisms,  electricity,  rubbing 
the  extremities,  applying  dry  heat,  etc.  In  fact,  Goltz's  beating  ex- 
periment fails  if  combined  with  vigorous  irritation  of  the  sensory 
nerves  of  the  extremities.  Internally,  warm  stimulating  drinks,  strong 
coffee,  hot  wine,  whiskey,  etc.,  should  be  administered ;  there  should 
also  be  given  subcutaneous  injections  of  camj)hor  or  calabar  extract, 
digitalin,  and  atropine.  Tincture  of  digitalis  can  be  tried  by  mouth 
instead  of  subcutaneous  injections  of  digitalin.  Dercum  has  highly 
recommended  the  rectal  use  of  a  musk  emulsion  (0.9  to  1.25  gramme), 
with  fifteen  drops  of  the  tincture  of  opium  or  an  enema  of  strong 
black  coffee.  The  respiration  must  be  carefully  watched,  and,  if  neces- 
sary, kept  up  artificially,  as  described  in  §  13.  One  must  avoid  under- 
taking an  operation  with  chloroform  narcosis  upon  a  patient  in  a  state 
of  shock.  The  chloroform  narcosis  may  alone  be  sufficient  to  cause 
the  weakly  contracting  heart  to  come  to  a  complete  standstill.  Patients 
who  are  suffering  from  shock  should,  as  a  rule,  not  be  operated  upon  ; 
but  if  it  is  absolutely  necessary  to  adopt  some  operative  measures,  such 
as  checking  hasmorrhage  or  the  like,  the  operation  should  be  done 
without  chloroform. 

§  64.  Delirium  Tremens. — By  delirium  tremens  (drunkard's  delirium) 
is  understood  an  acute  outbreak  of  chronic  alcoholic  poisoning,  which 
is  particularly  liable  to  occur  when  a  habitual  drinker  is  compelled, 
by  some  injury  or  acute  internal  disease,  to  remain  for  some  time  in 
bed.  Delirium  tremens,  owing  to  the  increase  in  the  misuse  of  alcohol, 
has  been  observed  in  youthful  subjects,  and  even  in  five-  to  eight-year- 
old  children.  These  children,  whose  parents  had,  as  a  rule,  been  ad- 
dicted to  drink,  had  for  a  long  time  been  taking  daily  increasing  amounts 
of  alcohol.  The  delirium  usually  breaks  out  very  soon  after  the  injury 
or  operation.  According  to  Krukenberg,  in  about  fifty  per  cent,  of  the 
cases  there  exists,  besides  the  alcohol  habit,  a  tendency  to  some  nerv- 
ous disease  such  as  epilepsy.  Krukenberg,  basing  his  opinion  on  three 
hundred  and  one  cases  of  alcoholism  which  he  observed,  among  which 
there  were  one  hundred  and  sixty-one  cases  of  delirium  tremens,  denies 
that  the  sudden  stoppage  of  alcohol  plays  a  causative  part  in  the  pro- 
duction of  delirium  tremens. 
22 


322  INFLAMMATION   AND   INJURIES. 

The  first  symptoms  manifested  are  loss  of  sleep,  great  restlessness, 
and  constant  talking.  The  trembling  movements  are  characteristic, 
and  particularly  evident  when  the  patient  is  told  to  hold  out  his  arm 
or  to  show  his  tongue.  The  patients  see  animals  of  every  description, 
and  they  are  very  aj^t  to  complain  that  their  rest  is  disturbed  by  mice, 
rats,  etc.,  crawling  about  them.  The  delirium  is  generally  connected 
with  marked  hallucinations,  and  not  infre(pently  there  is  pronounced 
maniacal  excitement.  They  try  to  get  up,  and  they  may  even  walk 
about  without  pain  though  they  have  a  fracture  of  the  leg.  They  make 
frequent  attempts  to  run  away,  and  consequently  must  be  carefully 
watched,  Yery  often  they  will  have  to  be  put  in  a  strait- jacket  and 
tied  in  bed.  The  prognosis  of  the  delirium  is  in  general  favourable, 
though  it  frequently  happens  that  old  people,  in  particular,  die  rather 
suddenly  with  symptoms  of  collapse.  It  must  also  be  borne  in  mind 
that  the  original  injury  from  which  such  a  patient  may  be  suffering — 
a  subcutaneous  fracture,  for  example — may  easily  run  an  unfavourable 
(complicated)  course  if  his  ^dolent  movements  are  not  carefully  enough 
guarded  against,  and  he  is  not  properly  treated.  The  post-mortem  ex- 
amination will  usually  reveal  the  ordinary  changes  which  occur  in  the 
organs  of  drunkards,  particularly  chronic  gastritis,  atheromatous  degen- 
eration of  the  arteries,  fatty  liver,  the  kidneys  of  Bright's  disease, 
thickening  of  the  cerebral  membranes,  etc. 

Treatment  of  Delirium  Tremens. — The  treatment  of  delirium  tremens 
consists,  in  the  first  place,  of  vigorous  prophylactic  measures.  It  is 
exceedingly  important  that  the  daily  amount  of  alcohol  which  the 
patient  has  been  accustomed  to  should  not  be  stopped,  and  even  more 
alcohol  should  be  given  during  his  illness  than  he  is  accustomed  to 
take  normally.  In  this  way  an  outbreak  of  delirium  tremens  can 
often  be  avoided.  Considerable  amounts  of  alcohol  should  be  admin- 
istered, best  in  the  form  of  strong  wine  or  cognac — about  one  half  to 
three  quarters  to  one  litre  in  twenty-four  hours ;  and,  in  addition,  the 
patient  should  be  given  an  easily  digestible  diet — meat,  l)ouillon  with 
eggs,  etc.  Furthermore,  it  is  a  good  plan  to  administer  opium  in  large 
doses  (0.10  to  0.40  gramme  every  two  hours),  with  or  without  coml)in- 
ing  it  with  tartar  emetic,  or  opium  with  chloral  hydrate,  or  morphine 
subcutaneously,  to  combat  the  restlessness  and  loss  of  sleep  from  which 
the  patient  suffers.  I  do  not,  as  a  general  thing,  like  these  narcotics  in 
the  treatment  of  delirium  tremens,  and  prefer  large  doses  of  alcohol, 
which  will  often  bring  on,  without  the  assistance  of  narcotics,  the  sleep 
which  is  the  precursor  of  a  speedy  convalescence.  I  employ  opium  or 
morphine  only  in  bad  cases  of  great  restlessness  or  mania.  When  the 
latter  condition  is  present,  it  is  an  excellent  plan  to  use  cold  douches, 


§65.]     DELIRIUM   NERVOSUM  AND   PSYCHICAL  DISTURBANCES.       323 

continued  for  a  considerable  length  of  time,  until  the  patient  is  put  1  o 
bed  in  an  exhausted  condition.  Sawadskje  praises  the  action  of  strjcli- 
nine,  which  he  exhibits  in  doses  of  0.003  gramme  for  a  week,  to  coun- 
teract the  desire  for  drink,  and  as  a  treatment  of  the  delirium  tremens 
and  the  conditions  which  it  gives  rise  to. 

§  65.  Delirium  Nervosum  and  Psychical  Disturbances  which  may  fol- 
low Injuries  and  Operations. — Bj  delirium  nervosum  is  understood  a 
condition  of  nervous  excitement  without  fever,  which  is  sometimes 
observed  in  hysterical  persons,  following  injuries  and  operations.  The 
delirium  mav  be  of  the  wild,  maniacal  type,  or  it  may  be  melancholic. 
Some  cases  have  the  character  of  hysteria,  or  senile  dementia.  The 
delirium  of  sepsis,  alcoholism,  and  poisoning  from  iodoform,  mor- 
phine, chloroform,  and  of  ursemic  states,  etc.,  of  course  do  not  belong 
to  this  class.  Le  L>entu  has  noted  over  twelve  cases  of  delirium  nervo- 
sum following  operations,  and  he  has  collected  sixty -eight  cases  from 
the  literature  on  the  subject,  thirty-eight  of  which  were  observed  after 
operations  on  the  female  genitalia.  Delirium  nervosum  generally 
makes  its  appearance  two  to  five  days  after  the  operation,  and  lasts 
several  days  or  a  week,  and  in  exceptional  cases  may  terminate  in 
death.  In  other  rarer  cases  there  are  real  mental  disturbances  with- 
out delirium  nervosum.  Advanced  age,  poor  nutrition,  23revious  men- 
tal or  nervous  disturbances,  and  particularly  hysteria,  are  predisposing 
factors.  In  the  majority  of  instances  the  psychical  disturbances  occur- 
ring in  connection  with  operations  upon  the  male  and  female  sexual 
organs,  or  following  operations  upon  the  face,  etc.,  are  of  a  transient 
nature.  Mention  should  also  be  made  of  the  delirium  of  collapse, 
which  is  occasionally  observed  after  a  sudden  fall  of  a  high  tempera- 
ture— for  instance,  after  the  defervescence  in  erysipelas,  and  in  hys- 
terical individuals  with  a  subnormal  temperature.  This  delirium  of 
collapse  is  usually  accompanied  by  transient  psychical  disturbances. 
The  prognosis  of  collapse  delirium  is  generally  favourable,  and  the 
acute  mental  aberration  often  disappears  in  a  few  days,  or  even  in 
a  few  hours.     The  treatment  of  delirium  nervosum  is  symptomatic. 

§  6Q.  The  Infectious-Wound  Diseases. — The  existence  of  infectious 
diseases  of  wounds  has  been  established  beyond  a  question  by  the 
labours  of  Pasteur,  Billroth,  Klebs,  Eberth,  and,  above  all,  by  Koch 
and  his  followers.  Thanks  to  their  careful  researches,  we  now  know 
that  the  infectious  diseases  of  wounds  are  caused  by  micro-organisms, 
or  by  the  products  of  their  metabolism  (ptomaines,  toxines).    (See  §  59.) 

Koch,  experimenting  upon  animals,  excited  infectious-wound  dis- 
eases which  possessed  many  similarities  to  corresponding  diseases  in 
man.     However,  the  facts  which  are  experimentally  ascertained   as 


324:  INFLAMMATION  AND  INJURIES. 

regards  animals  cannot  be  directly  applied  to  man,  as  we  know  that 
different  species  of  animals  are  affected  differently  by  the  same  poisons. 
A  poison  or  a  certain  species  of  bacteria  may  not  be  injurious  for  one 
kind  of  animal,  while  this  same  jjoison  may  immediately  excite  danger- 
ous symptoms  in  another.  Furthermore,  totally  different  classes  of 
micro-organisms  may  produce  in  different  animals  diseases  which  are 
very  similar.  The  bacillus  of  mouse  sepsis  is  totally-  different  from 
the  bacillus  which  causes  sepsis  in  rabbits,  and  it  does  not  cause  sepsis 
in  the  latter.  The  sepsis  which  occurs  in  mice  from  infection  by  a 
bacillus  has  only  been  observed  in  house-mice,  while  field-mice  are 
immune  from  its  effects,  etc. 

Koch  was  the  first  to  develop  an  exact  method  for  investigating 
the  infectious  diseases  of  wounds.  He  introduced  improved  methods 
of  illuminating  and  staining  preparations,  and  thus  made  it  possible 
for  us  to  study  the  shape,  distribution,  and  number  of  the  bacteria  in 
the  body.  He,  moreover,  made  cultures  of  the  bacteria  which  he  had 
found  upon  solid  nutritive  media,  so  as  to  observe  the  characteristics 
of  their  growth  and  the  immutability  of  their  species.  These  pure 
cultures  were  then  reinoculated  upon  animals,  for  the  purpose  of  ex- 
citing the  same  disease  which  they  had  first  caused.  We  have  these 
exact  methods  of  his  to  thank  for  our  knowledge  of  the  etiology  of  the 
infectious  diseases  of  wounds,  and  the  facts  ascertained  by  experi- 
ments upon  animals  conform  very  closely  to  what  we  have  observed 
in  man. 

Every  inflammation  and  suppuration  of  the  wound,  circumscribed  and 
diffuse  cellulitis,  acute  inflammations  of  the  lymph  and  blood-vessels 
(lymphangitis,  phlebitis,  arteritis),  erysipelas,  hospital  gangrene  (wound 
diphtheria),  pyeemia,  septicaemia,  and  tetanus,  are  all  included  among 
the  secondary  infectious  diseases  of  wounds  which  may  make  their  ajD- 
pearance  in  man.  These  infectious- wound  diseases  are  all  caused  by 
bacteria.  This  class  of  diseases  also  includes  anthrax,  hydrophobia, 
glanders,  etc.,  which  are  diseases  communicated  from  animals  to  man. 
Actinomycosis,  tuberculosis,  and  syphilis  are  also  due  to  infection  by 
micro-organisms,  and  there  are  still  other  diseases  of  a  like  character 
which  we  shall  learn  about  later.  The  bacteria  are  capable  of  gaining 
access  to  the  tissues  or  the  fluids  of  the  body  through  any  wound,  even 
the  smallest  interruption  in  the  continuity  of  the  skin  or  mucous  mem- 
branes. Schimmelbusch,  Ricker,  ]^oetzel,  and  others  in  experimenting 
with  animals  were  able  to  demonstrate  bacteria  in  the  blood  ten  minutes 
after  infection  of  a  fresh  wound.  This  absorption  of  bacteria  from  the 
wound  is,  however,  usually  of  no  importance  to  the  organism,  as  it  is 
only  the  non -pathogenic  bacteria  that  are  so  quickly  absorbed,  and  not 


§66.]  THE   INFECTIOUS-WOUND  DISEASES.  325 

the  pathogenic.  During  the  first  four  to  six  hours  the  infection  is  only 
a  local  one,  but  after  this  the  further  increase  in  the  number  of  bacteria 
and  their  metabolic  products  brings  with  it  danger  to  the  organism. 
The  bacteria  and  their  metabolic  products  are  attacked  and  sometimes 
.neutralized  by  the  protective  substances  (antitoxines)  already  present 
in  the  body  or  formed  by  the  poisonous  action  of  bacteria.  This  takes 
place  in  the  different  organs,  and  particularly  in  the  blood-serum.  If 
the  infection  is  a  very  virulent  one,  or  if  the  antitoxines  are  not  present 
in  sufficient  amount,  death  of  the  individual  will  be  the  result.  Bacteria 
cannot  enter  the  circulating  blood  or  lymph  through  intact  granulating 
wounds  or  surfaces,  and  their  metabolic  products  are  probably  also  not 
absorbed  from  such  wounds.  The  superficial  cellular  layer  covering 
the  blood-vessels  and  lymphatics  acts  like  the  epidermis,  and  the  secre- 
tion of  the  wound  helps  in  a  mechanical  way  by  washing  the  bacteria 
from  the  granulating  surface. 

As  regards  the  occurrence  of  infectious  diseases  of  wounds,  the  local 
and  general  predisposition  of  the  individual  plays  an  important  part. 
It  is  true,  however,  that  little  is  known  of  the  nature  of  these  anatomi- 
cal, physiological,  or  chemical  differences  that  occur  in  different  indi- 
viduals. The  best  way  oi  jyreventing  an  infectious-wound  disease  is  to 
employ  the  most  careful  asepsis  or  antisepsis  in  every  operation  or 
injury  and  in  the  application  of  every  dressing.  The  possibilities  of 
surgery  since  the  introduction  of  antiseptic  and  aseptic  methods  have 
increased  to  a  most  wonderful  degree,  and  our  responsibility  towai'ds 
our  patients  has  become  correspondingly  greater.  Every  physician 
should  constantly  bear  in  mind  that  he  may  cause  the  death  of  his 
patient  by  a  single  transgression  of  the  rules  of  asepsis — by  an  unsteril- 
ised  and  non-aseptic  instrument,  or  by  an  unclean  finger.  Every  fresh 
wound  contains  bacteria,  and  consequently  should  be  thoroughly  washed 
out  as  soon  as  possible  with  some  aseptic  or  antiseptic  solution  in  order 
to  remove  the  clots  which  contain  bacteria  and  the  other  impurities 
from  the  wound.  It  is  difficult,  and  in  fact  impossible,  to  kill  all  the 
bacteria  by  means  of  our  antiseptics,  but  at  the  same  time  it  is  wiser  to 
recommend  that  the  physician  in  general  practice  employ  antisepsis  in 
injuries  rather  than  asepsis. 

The  infectious  diseases  of  wounds  have,  corresponding  to  the  action 
of  the  bacteria,  partly  a  local  and  partly  a  general  systemic  character. 
As  was  stated  in  §  62,  the  general  disturbances,  the  fever,  and  the  gen- 
eral poisoning  are  caused  by  the  absorption  of  the  metabolic  products 
of  the  fungi,  which,  as  we  shall  see  when  we  come  to  septicaemia,  can 
give  rise  to  systemic  poisoning  even  after  they  have  become  separated 
from  the  fungi.     Their  metabolic  products  thus  give  rise  to  an  intoxi- 


326  INFLAMMATION  AND  INJURIES. 

cation  which,  Hke  every  kind  of  poisoning  hx  chemical  substances,  can- 
not be  transmitted  by  inoculation.  Infectious  diseases  caused  by  the 
bacteria  themselves  are,  on  the  contrary,  capable  of  being  transmitted 
from  one  individual  to  another.  AYe  shall  see  that  each  one  of  the  in- 
fectious-wound,  diseases  to  which  man  is  subject  is  excited  by  a  specific , 
micro-organism.  There  are  cases,  however,  which  are  not  due  to  in- 
fection by  any  single  species  of  bacteria,  but  are  mixed  infections — in 
other  words,  they  are  caused  by  several  different  species  acting  together. 
The  questions  concerning  the  significance  of  the  micro-organisms  in 
the  causation  of  the  infectious-wound  diseases  and  the  various  methods 
for  investigating  them  have  been  described  in  §  59. 

In  all  febrile  infectious  diseases  of  bacterial  origin  the  cause  of  the 
fever  is  to  be  ascribed  to  the  changes  in  the  blood  brought  about  Ijy 
the  bacteria,  or  the  poisonous  products  of  their  metabolism  (toxines). 
Furthermore,  in  the  fevers  due  to  unformed  ferments,  or  non-bacterial 
solutions,  such  as  albumoses,  nucleins,  fibrin  ferment,  pepsin,  trypsin, 
or  haemoglobin,  it  is  principally,  as  described  in  §  62,  the  change  in  the 
composition  of  the  blood  which  gives  rise  to  the  increased  oxidation 
processes  going  on  in  the  blood,  and  to  the  rise  of  temperature. 

§  67.  Inflammation  and  Suppuration  of  a  Wound — Etiology. — Though 
it  was  once  believed  that  all  suppuration  was  caused  by  micro-organisms, 
we  learned  on  page  2-41  that  Grawitz,  De  Barry,  and  others  have  dem- 
onstrated that  suppuration  can  also  be  excited  without  bacteria  in  dogs 
and  rabbits  by  aseptic  (germ-free)  chemical  substances,  such  as  turpen- 
tine, nitrate  of  silver,  mercury,  etc.  Moreover,  sterilised,  cultures  of 
various  micro-organisms,  or  the  sterilised  products  of  their  metabolism 
(cadaverine,  putrescine,  pentamethylendiamine),  have  a  similar  (pyo- 
genic) power  of  exciting  suppuration.  When  Behring  added  iodoform 
to  the  cadaverine  the  latter  never  produced  suppuration. 

Though  it  is  undoubtedly  true  that  suppuration  can  be  excited  by  a 
whole  series  of  germ-free  chemical  substances,  it  is  just  as  certain  that 
suppuration  is  produced  in  man,  under  ordinary  conditions,  by  the 
presence  and  life  of  certain  distinct  micro-organisms,  no  matter  whether 
the  suppuration  takes  the  form  of  a  simple  felon,  a  furuncle,  or  a  dan- 
gerous phlegmon.  The  question  does  not  involve  two  opposing  prin- 
ciples, since  the  l)acteria  themselves  give  rise  to  suppuration  mainly 
through  the  chemical  products  of  their  metabolism.  Ogston,  Rosen- 
bach,  and  others  have  studied  the  micro-organisms  which  are  present 
in  acute  suppuration,  and  they  have  frequently  found  only  a  single 
species,  but  at  other  times  several.  Suppuration  in  man  is  mainly  due 
to  cocci,  which  are  found  either  in  irregular  masses  arranged  in  groups 
(the  staphylococcus,  Fig.  293),  or  in  tlie  form  of  chains  (the  strepto- 


§67.]  INFLAMMATION  AND   SUPPURATION   OF   A  WOUND.  327 

COCCUS,  Fig.  296).  The  streptococcus  is  more  apt  to  give  rise  to 
spreading  erysipelatous  inflammations,  the  staphylococcus  to  localised 
inflammation  and  suppuration,  and  the  latter  is  the  true  pus  coccus. 
Blood  taken  from  human  subjects  with  suppurative  processes  and  in- 
jected into  mice  will,  even  though  it  contain  no  germs,  poison  mice 
and  they  die  within  twenty-four  hours  (Nissen). 

All  bacteria  found  in  acute  pus  foci  cause  milk  to  coagulate.  That 
the  pyogenic  bacteria  should  cause  in  some  cases  only  mild  suppuration, 
and  in  others  severe  spreading  cellulitis  that  threatens  the  life  of  the 
patient,  and  in  still  others  acute  osteomyelitis  or  metastatic  pyaemia,  is 
explainable  partly  by  the  difference  in  the  point  of  invasion  and  partly 
by  the  variability  in  the  virulence  and  the  number  of  the  micro-organ- 
isms. It  is  of  interest  that  the  pus  microbes  act  very  differently  in 
aerobic  and  anaerobic  cultures.  The  pus  cocci  concerned  in  a  suppura- 
tive process  in  the  body  can  often  be  detected  in  the  blood,  urine,  and 
sweat.  In  exceptional  cases  the  pus  in  an  acute  suppurative  process 
contains  no  bacteria.  But  this  does  not  prove  that  they  were  not  pres- 
ent at  first,  for  we  know  that  there  are  bacilli  which  cause  suppuration, 
and  then  die  very  soon.  Old  abscesses  frecpently  contain  no  patho- 
genic bacteria.  The  lodgment  of  pus  cocci,  or  rather  the  starting  up 
of  suppuration,  is  favoured  by  local  lesions  as  well  as  by  weakness  of 
the  whole  organism. 

The  most  Important  Pus  Microbes. — 1.  The  Stax^hylococcus pyogenes 
aureus  (Figs.  293,  294),  so  designated  because  of  its  golden  or  orange-yellow 
colouring  matter,  is  the  species   of  micro- 
coccus which  is  most  frequently  found  in  & 
suppuration.     (According  to  Frankel,  it  is                    c?!>0  '^^ 
found  in  eighty  per  cent,  of  all  the  cases  ex-                  ■•                 ?«^p.  ^P  ,<jr 
amined.)     These  cocci  are  incapable  of  mo-       .x            '  '  1   ^     •        M^' 
tion,  vary  in  size,  and  are  arranged  in  clus-      N^^*  •-*"  ^^^^         ^^ 
ters,  often  in  the  form  of  diplococci.     It  is            ^        -  *;:^^P*^^      ..^^ 
present  in  pus.  in  the  air,  in  dish-water,  and              -••          ^    • .     <;?'    'i-""  j 
in  the  earth.    TYvo.  Staphylococcus  p)yogenes                         v.    "mm  -' 
aureus  can  be  grown  in  pure  cultures  upon              ^        ^         _      ^»  ^. 
gelatine,    agar-agar,    potatoes,    and    blood-        r^^^^       ^^        ^^^T 
serum.     In  gelatine  plate   cultures,  at  the        "■                    '■^5 
end  of  the  second   day,  small   punctiform                            ^^ 
colonies  appear,  having  a  yellow  colour  and     Fig  293  — Pu^  cells  md  stiphvlococci 
a  sharp,  slightly  depressed  border,  separat- 
ing them  from  the  non-fluid  gelatine.     Puncture  cultures  in  gelatine  at  first 
reveal  a  dim,  greyish  point,  which  after  about  three  days  becomes  yellowish, 
and  then  orange-coloured  ;  then  the  gelatine  becomes  liquefied,  and  the  cul- 
ture sinks  to  the  bottom.     Linear  cultures  upon  agar-agar  (Fig.  294)  give  an 
opaque  yellow  culture  which  has  a  crooked  oiitline.     Upon  potatoes  there 
first  forms  a  thin,  whitish  layer,  which  gradually  becomes  orange-yellow, 


328 


INFLAMMATION  AND  INJURIES. 


S"*«»v 


1- 


and  smells  like  paste.  The  Staphylococcus  pyogenes  aureus  grows  in  blood 
serum  in  the  same  way  as  upon  agar-agar.  All  cultures  develop  pretty 
rapidly — particularly  at  temperatures  between  30°  and  37°  C.  (98.6°  F:),  and 
moi'e  slowly  at  ordinary  room  temperatures.  They  have  not  hitherto  been 
seen  to  form  spores.  Tliis  coccus  possesses  great  powers 
of  retaining  its  vitality,  and  is  exceedingly  resistant,  for 
instance,  to  drying,  chemical  substances,  and  boiling 
water.  To  the  latter  it  lias  to  be  subjected  for  several 
minutes  before  it  is  killed.  The  Staphylococcus  p?/o- 
genes  aureus  can  exist  a  great  while  without  atmos- 
pheric air,  is  facultative  aerobic,  and  gives  rise  to  the 
formation  of  no  gas  or  foul  decomposition ;  it  pepto- 
nises  albumen  and  liquefies  gelatine.  Gram's  method 
is  excellent  for  staining  the  Staphylococcus  p>yogenes 
aureus. 

The  pathogenic  effect  of  the  Staphylococcus  2^yo- 
genes  aureus,  when  used  experimentally  upon  animals, 
varies  with  the  manner  in  which  it  is  employed  and 
the  kind  of  culture  used.  Cultures  in  large  amounts 
can  sometimes  be  injected  into  the  peritoneal  cavity 
without  causing  peritonitis  (Baumgarten,  Burginski). 
Inoculations  have  been  made  upon  man  by  various  ex- 
perimenters. Garre  inoculated  himself  by  inserting  a 
pure  culture  in  a  small  wound  at  the  root  of  his  finger- 
nail, and  obtained  an  extensive  suppuration ;  by  rub- 
bing a  great  number  of  the  cocci  upon  the  healthy,  un- 
broken skin  of  his  forearm  he  produced  a  large  carbun- 
cle. Subcutaneous  inoculations  in  mice,  guinea-pigs, 
and  rabbits  are  without  any  result,  though  subcutaneous 
injections  in  the  two  latter  classes  of  animals  give  rise 
to  the  formation  of  abscesses.  Injections  made  into  the 
peritoneal  cavity  usually  cause  a  violent  suppurative  in- 
flammation, which  kills  the  animal  in  a  few  days.  Iii- 
jections  of  the  cocci  into  the  blood-vessels  give  rise  to 
inflammations  of  joints  and  to  diseases  of  the  kidneys, 
and  metastatic  abscesses  develop  in  the  muscles  of  the 
heart  and  in  the  kidneys.  If  the  valves  of  the  heart 
are  first  wounded,  a  typical  endocarditis  ulcerosa  results. 
If,  before  injecting  the  cocci  into  a  blood-vessel,  a  sub- 
cutaneous fracture  or  crush  of  one  of  the  long  hollow  bones  is  artificially 
produced,  the  point  at  which  the  injury  is  situated  becomes  "  predisposed  " 
to  suppurative  inflammation  of  the  medullary  portion  and  periosteum.  The 
Staphylococcus  j^ogenes  aureus  is  the  most  frequent  excitant  of  acute 
osteomyelitis  (see  §  104).  Frequently  the  Staphylococcus  jjyogenes  aureus 
is  found  combined  with  other  micro-organisms  in  cases  of  suppuration.  The 
toxines  of  the  staphylococcus  act  very  differently  in  different  animals  upon 
the  heart,  respiration,  and  nervous  system.  The  leucocytes  are  quickly 
destroyed  by  a  poison  to  which  Velde  gave  the  name  of  leucocidin.  Accord- 
ing to  Bail,  this  is  formed  by  various  other  bacteria. 


Fig.  294.— Linear  cul 
turo  in  agar-agar— 
Staphylococcus  pyo 
qenes  aureus. 


67.] 


INFLAMMATION  AND   SUPPURATION  OF   A  WOUND. 


329 


2.  The  Staphylococcus  pyogenes  albus  is  in  all  respects  similar  to  the 
Staphylococcus  pyogenes  aureus,  except  in  not  having  the  latter's  yellow 
colouring  matter.     It  also  appears  to  be  somewhat  less  harmful,  and  is 

of  less  frequent  occurrence  than  the  aureus.     It  has  been       r — ■■ — ' -.7 

known  to  cause  ha3morrhagic  purpura  of  the  skin  (Silverstein,        '  , 

Boduel,  etc.). 

3.  The  Staphylococcus  pyogenics  citreus  was  discovered 
by  Passet,  and  is  seldom  found  in  suppurative  processes  in 
man.    The  Staphylococcus  pyogenes  citreus  is,  d\s,i\ag\xi&\\e6. 

by  its  beautiful  lemon-yellow  pigment  (Fig.  267),  but  is  other-  ', 

wise  exactly  like  the  aureus  and  albus,  except  that  it  takes 
longer  to  liquefy  gelatine. 

Streptococcus  Pyogenes.— 4.  The  Streptococcus  pyogenes 
(Fig.  296)  plays  a  very  important  part  in  the  causation  of  sup- 
puration.    It  is  frequently  found  alone  in  abscesses,  rarely  ^ 
in  combination  with  the  staphylococci.     This  coccus  causes, 
for  the  most  part,  progressive  suppuration,  and  from  recent  I 
discoveries  is  identical  with  Fehleisen's  streptococcus  of  ery-  ^ 
sipelas.     In  the  latter  disease  the  streptococcus  is  found  prin-                        J 
cipally  in  the  lymph  channels  of  the  skin.     The  streptococci                        3 
form  chains  generally  consisting  of  six  to  ten  to  twenty  cocci                        4 
arranged  in  a  row  like  links,  though  there  may  be  hundreds 
of  these  cocci,  or  links,  in  a  single  chain.     The  chains  are 
often  made  up  of  two  parts,  or  they  may  be  twisted  together 
in  thick  masses,  or  arranged  in  slender  bundles.     The  follow- 
ing are  the  principal  facts  as  regards  the  development  of  pure 
cultures  :  Gelatine  plate  cultures  take  the  form  of  fine,  round, 
granular  dots.    Linear  cultures  upon  gelatine  plates  are  thickest  at  the  centre 
of  the  line,  of  a  faint  brown  colour,  with  the  edges  of  the  line  plainly  punc- 
tate, and  later  becoming  graded  off  in  terraces.     Puncture,  or  stab  cultures, 

in  gelatine,  have  a  delicate 
areola  at  the  point  where  the 
puncture  enters  the  gelatine, 
the  line  of  puncture  itself 
being  finely  granular  (Fig. 
295).  The  streptococcus  does 
not  multiply  upon  jaotatoes, 
though  some  individual  cocci 
increase  in  size,  and,  when 
examined  by  the  microscope, 
chains  are  seen  made  up  of 
some  large  and  some  small 
cocci  or  links.  The  Strepto- 
coccus pyogenes  grows  best 
at  a  temperature  of  35°  to  87°  C.  (98.6°  F.),  ordinary  room  temperatures  being 
less  favourable  to  them.  The  cultures  grow  slowly,  linear  cultures  requiring 
two  to  three  weeks  to  spread  a  couple  of  millimetres.  After  the  lapse  of  four 
months  the  cultures  will  be  found,  for  the  most  part,  to  have  perished. 
Gelatine  is  not  liquefied ;   it  decomposes  albumen  in  a  vacuum ;  it  is  fac- 


FiG.  295.— Stab 
or  puncture 
culture  of 
Streptococcus 
pyogenes. 


l.^-- 


.' 


•O 


Fig.  296.- 


'...<^ 


-a.  Streptococcus,  x  950 ;  i,  pus  with  strepto- 
coccus. 


330  INFLAMMATION  AND   INJURIES. 

ultative  aerobic,  and  is  not  particularly  atfected  bj"  the  absence  of  oxy- 
gen. It  is  best  stained  by  Gram's  method.  The  Streptococcus  pyogenes 
can  be  found  almost  anywhere,  and  its  pathogenic  etfects  may  be  mani- 
fested in  various  ways,  according  to  the  manner  and  the  region  in  which 
it  gains  access  to  the  body.  It  is  found  in  saliva,  nasal  and  vaginal 
mucus,  and  in  the  ux*ethra  of  man  in  health.  It  is  often  found  in  tissues 
which  have  undergone  morbid  changes — for  example,  in  typhoid  fever, 
pneumonia,  tuberculosis,  pleurisy,  and  scarlet  fever,  and  under  such  con- 
ditions it  may  give  rise  to  severe  inflammatory  complications.  By  itself  it 
causes  inflammatory  processes  and  suppuration,  which  often  lead  to  septi- 
caemia, and  are  characterised  by  a  marked  tendency  to  extension  along  the 
surface.  It  is  a  frequent  excitant  of  puerj^eral  fever.  Upon  the  valves  of 
the  heart  it  excites  typical  endocarditis.  When  growing  in  the  lymph  chan- 
nels of  the  skin  and  mucous  membranes  it  causes  cutaneous  erysipelas  and 
destructive  inflammation  of  the  mucous  membranes,  and  when  lodged  in  the 
subcutaneous  tissue  it  gives  rise  to  cellulitis,  etc.  The  streptococcus  produces 
fatal  toxines,  particulai'ly  if  air  is  excluded  (Roger).  Antistreptococcus  serum 
has  been  successfully  used  in  a  number  of  cases  of  streptococcus  infection — 
e.  g.,  peritonitis,  puerperal  fever,  and  erysipelas.  In  other  cases  the  results 
have  been  negative,  and  I  doubt  whether  its  practical  value  has  yet  been 
proved. 

Bacillus  Pyocyaneus.— The  Bacillus  pyocyaneus,  or  the  bacillus  of  green 

or  blue  pus,  occurs  in  different  forms — e.  g.,   as  the  Bacillus  pyocyaneus 

a  Gessard  or  pyofluorescens,  and  as  Bacillus  joyocyaneus  /S  Ernst.    It  is  a 

small  slender  rod  (Fig.  297),  and  is  found  in  the  air,  earth,  and  water,  as  well 

as  in  the  tissues  and  fluids  6f  man  and  diflrerent  animals.    This  bacillus  gives 

a  blue  or  green  colour  to  i^us  and  the  dressings  without 

,jA'iHl);t''^  causing  any  complication  in  the  healing  process.     It  is 

'\^   'Iw^Jl*^*^    X      similar  to  the  bacillus  of  blue  milk,  but  is  somewhat  nar- 

^  \i   /^''"'*'^\'  ^   '      rower.     It  is  capable  of  very  active  movements,  and  is  fre- 

t'  $((\r',^ '  9^^  quently  found  in  the  form  of  bands  with  four  to  six  joints, 

'  1''^^  and  less  frequently  in  the  form  of  long  filaments.    Accord- 

FiG.  297.— Bacilli  of      ing  to  Schimmelbusch,  it  forms  not  only  green  or  blue 
greenisli-blue  pus.         .  .    i     ^      i        i  i      n     i  ->      • 

X  700.  pigment,  but  also  brown  and  all  the  gradations  between 

green  and  brown.  The  pigment  formation  depends  upon 
the  amount  of  air,  the  proper  nutritive  medium,  and  upon  the  condition  of 
the  bacilli.  The  latter  may  lose  their  power  of  forming  pigment  in  both  an 
artificial  and  a  natural  way.  When  cultivated  on  gelatine  plates  small  white 
points  are  formed  within  the  gelatine,  then  come  to  the  surface,  and  spread 
out.  The  culture  medium  takes  on  early  a  green  fluorescent  colour  for  some 
distance  around  the  cultures,  and  by  the  fifth  day  the  gelatine  has  become 
completely  liquefied.  In  a  test  tube  the  bacillus  develops  almost  exclusively 
in  the  deeper  parts  of  a  stab  culture.  The  gelatine  becomes  rapidly  lique- 
fied, and  assumes  a  beautiful  green  colour.  Upon  agar-agar  there  forms  a 
moist,  rather  thick  yellow  covering,  which  colours  the  nutritive  medium 
green.  Upon  potatoes  there  is  developed  a  dirty  yellowish-green  scum,  with 
a  green  discolouration  of  the  adjoining  parts.  The  colouring  matter  (pyo- 
cyanine)  is  for  the  most  pai-t  seen  at  the  free  borders  of  the  clusters,  and,  ac- 
cording to   Ledderhose,  is  an  aromatic   crystalline  compound   having   no 


§67.]         INFLAMMATION  AND  SUPPURATION  OF  A  WOUND.  331 

pathogenic   properties.     According  to  C.  Frankel,  the  colouring  matter  is 

white  when  first  formed  from  the  bacteria,  only  assuming  its  peculiar  tinge 

when  brought  in  contact  with  the  oxygen  of  the  air.     The  bacilli  themselves, 

and  the  products  of  their  metabolism,  are  undoubtedly  injurious  to  animals. 

If  about  one  cubic  centimetre  of  a  fresh  bouillon  culture  is  injected  into  the 

subcutaneous  ■  tissue  of  a  guinea-pig  or  rabbit  there  will 

result  a  rapidly  spreading  oedema  and  suppurative  inflam-  \   ,  ---:^s>,-. 

mation,  causing  the  death  of  the  animal  in  a  short  time.       ,"»    ^.'    ','j>i'Sf0 

The  bacilli  will  be  found  at  the  point  of  inoculation,  in  the       '. '    •';  ,\  '>'''^rik'P'' 

blood,  and  in  the  internal  organs.     According  to  Schim-         ,j;  '{-tfr  €/-  '-p;^ 

melbusch,  the  Bacillus  pyocyaneus  exerts  a  poisonous  "'  '.-jJ-r'^fl,'/,"^ 

local  and  general  action,  but  it  does  not  possess  in  general  '  ''"'"*' 

the  properties  of  an  active  pathogenic  micro-org-anism.    In     -^'^-    298.— ^aciZ^ws 
■^      -^  ,.„..,  pyogenes  fmtidus 

rare  cases  general  infections  with  the  Bacillus  ijyocyaneus  (Fasset). '  x  700. 
do  occur  (typhoid  condition,  enlargement  of  the  spleen, 
haemorrhages  from  rupture  of  the  weakened  blood-vessels,  gangrenous  ecthy- 
ma pustules,  etc.).  Bouchard  and  Charrin  have  demonstrated  the  very  inter- 
esting fact  that  it  is  possible,  with  the  aid  of  the  Bacillus  ijyocyaneus,  to 
check  an  advancing  anthrax  infection  and  to  cause  it  entirely  to  disappear. 
The  injection  of  the  toxines  of  the  pyocyaneus  has  an  antipyretic  action 
causing  the  body-temperature  to  fall  (Langlois  and  Charrin). 

Bacillus  Pyocyaneus  /3  Ernst.— Ernst  has  described  a  variety  of  the  Ba- 
cillus pyocyaneus  as  the  /3  Bacillus  pyocyaneus.  It  forms  a  blue  colouring 
matter,  or  rather  blue  pus,  while  the  other  (a)  bacillus  forms  the  green  pig- 
ment. Ledderhose  has  designated  the  a  bacillus  Bacillus  pyofluorescens 
and  the  /3  bacillus  Bacillus  p>yocyaneus  /3.  Generally  the  two  kinds  of 
bacilli  occur  together  and  produce  a  mixed  colour. 

Other  Colouring  Matters  Produced  by  Bacillus  Pyocyaneus.— Schimmel- 
busch  states  that  the  Bacillus  pyocyaneus  forms,  in  addition  to  the  green  or 
blue  colouring  matter,  brown  and  a  whole  series  of  colouring  matters  rang- 
ing all  the  way  from  brown  to  green.  The  production  of  the  colouring  de- 
pends upon  the  presence  of  sulfi^cient  air,  proper  nutritive  media,  and  upon 
the  structure  of  the  bacilli.  The  latter  may  assume  different  forms  in  differ- 
ent nutritive  media,  and  may  even  be  unable  to  lose  their  property  of  pro- 
ducing colouring  matters  under  natural  or  artificial  conditions. 

Red  Pus. — There  is  occasionally  observed  a  red  cinnabar-coloured  pus. 
Ferchmin  found  that  the  causation  of  this  red  pus  was  to  be  asci'ibed  to  a 
special  form  of  bacillus  with  evenly  rounded  ends,  which  could  be  cultivated 
best  at  a  temperature  of  36°  to  37°  C.  in  various  nutritive  media — agar-agar, 
gelatine,  blood-serum,  potatoes.  The  red  colouring  matter  is  easily  soluble 
in  alcohol,  and  is  insoluble  in  water,  ether,  and  chloroform.  In  man,  tlie 
red  colour  of  the  pus  has  nothing  to  do  with  the  reparative  process  in  a 
wound.     In  rabbits  especially  the  bacillus  has  pathogenic  properties. 

Other  Pus  Microbes. — Among  the  other  pus  microbes  mention  should  be 
made  of  the  Micrococcus  pyogenes  tenuis,  the  Bacillus  p)yogenes  foetidus 
Passet  (Fig.  298),  the  Proteus  vulgaris,  the  Staj^hylococcus  cereus,  albus,  and 
flavus,  and  Friedlander's  pneumococcus.  The  majority  of  these  bacteria  are 
of  subordinate  importance  as  regards  man.  Recently  the  Bacillus  pyogenes 
foetidus  has  been  carefully  studied  by  Burci.    He  proved  that  it  possessed  not 


332  INFLAMMATION   AND  INJURIES, 

only  pyogenic  but  even  septic  propei'ties  for  rabbits  and  mice,  and  sometimes 
produces  in  man  severe  acute  suppuration,  which  has  also  been  observed 
in  the  case  of  Friedlander's  pneumococcus.     Neumann  and  Haeg-ler  main- 
tain that  the  Micrococcus  pyogenes  ten- 
nis is  identical  with  the  pneumococcus  of 
/  Friinkel  and  Weichselbaum.      Friinkel's 

|-  ^l'^     pneumococcus  (Fig.  299),  the  typhoid  ba- 

'  W?^     ^-jj-  ^-p-g  2Q2,  page  263),  and  the  Bacte- 

rium coll  commune  all  produce  suppura- 
tion. FrtinkeFs  pneumococcus,  which  has 
been  found  to  be  the  cause  of  various 
forms  of  inflammation  and  suppuration 
— e.  g.,  pneumonia,  empyema,  meningitis, 
2^      „^  r  peritonitis,  etc. — possesses  a  large  capsule, 

^ ^^  *  ~  and  is  hence  known  as  the  capsule  coccus. 

In  other  cases  the  suppurative  processes 

Fig.  299.— Diplococcus  of  Frankel  (cap-       ^i     .  cioour  in    thp  pmirsP  of  fhp  apiitP  ui- 

sule  coccus).    Fus  taken  from  a  case      i^nat  occui   m  tne  couise  ot  t(ie  acute  m 

of  empyema,     x  1,000.  fectious  diseases  are  caused  by  mixed  in- 

fection with  the  ])us  cocci. 

The  mici'ococcus  w^hich  causes  suppurative  inflammation  of  the  urethra, 
the  vagina,  etc. — in  other  words,  the  gonococcus  Neisser — is  discussed  in 
Eegional  Surgery. 

Chronic  abscesses,  apart  from  those  due  to  syphilis,  glanders,  and  actino- 
mycosis, are  for  the  most  part  tubercular,  and  are  caused  by  a  characteristic 
bacillus  (Koch). 

Animals  have  been  rendered  immune  against  pus  cocci,  partly  by  inocu- 
lation of  weakened  cultures  of  the  same,  and  partly  by  injection  of  the  tox- 
ines  isolated  from  the  bacteria.  The  serum  of  such  animals,  particularly 
those  made  immune  by  the  latter  method,  will  render  other  animals  unsus- 
ceptible to  infection,  and  will  cure  the  infection  already  present  (see  also 
antistreptococcus  serum,  page  330), 

Different  Forms  of  Inflammation  and  Suppuration  as  we  meet  them  in 

Surgery.— Clinically,  iutlammation  and  suppuration  may  exist  in  various 
forms,  either  as  an  ordinary  superficial  suppuration  limited  to  the 
wound,  or  the  inflammation  may  extend  to  the  parts  in  the  neighbour- 
hood of  the  injui-y  and  result  in  a  cellulitis.  This  inflammation  may 
lead  to  more  or  less  circumscribed  suppuration  and  abscess,  or  to  dif- 
fuse and  often  rapidly  spreading  inflammatory  and  suppurative  pro- 
cesses. The  worst  form  of  spreading  inflammation  and  suppuration  is 
the  diffuse,  foul-smelling  inflammation  of  the  cellular  tissue,  to  which 
is  given  the  name  of  septic  phlegmon.  Inflammation  of  the  lymph 
vessels  is  called  lymphangitis.  Inflammations  of  the  vessels,  especially 
the  veins  (phlebitis),  are  very  important,  particularly  as  regards  their 
dangerous  sequelae,  due  to  the  so-called  emboli.  The  spreading  inflam- 
mation which  involves  the  skin  and  subcutaneous  cellular  tissue,  the  so- 
called  erysipelas,  is  caused  by  an  inflammation  of  the  smaller  lymph 


§68.]  LYMPHANGITIS,  LYMPHADENITIS,  333 

channels,  due  to  the  Streptococcus  pyogenes.  The  gangrenous  breaking 
down  of  a  granulating  wound  is  called  hospital  gangrene,  or  wound 
diphtheria.  Accompanying  the  inflammation  and  suppuration  caused 
by  micro-organisms,  there  is  more  or  less  fever,  due  to  secondary  infec- 
tion or  poisoning  of  the  lymph  and  blood  by  the  bacteria  and  the 
products  of  their  metabolism.  This  may  finally  terminate  in  a  fatal 
general  systemic  poisoning,  which  we  shall  learn  about  more  particu- 
larly under  the  heading  of  Pygemia  and  Septicaemia. 

We  shall  first  discuss  acute  inflammation  of  the  lymph  vessels 
(lymphangitis)  and  lymph  glands  (lymphadenitis). 

§  ^^.  Lymphangitis,  Lymphadenitis.  Acute  Ijiflammation  of  the 
Lymph  Vessels — ■  Lymphangitis. — Acute  lymphangitis  is  characterised 
partly  by  a  change  in  the  lymph  and  walls  of  the  lymph  vessels,  and 
partly  by  a  perilymphangitis — i.  e.,  an  inflammation  of  the  connective 
tissue  surrounding  the  lymph  vessels.  The  starting-point  of  a  lym- 
phangitis is  usually  some  focus  of  infection  ;  in  other  words,  it  is  par- 
ticularly apt  to  originate  from  an  infected  wound.  The  interruption 
of  continuity  in  the  skin  is  frequently  most  insignificant.  The  inflam- 
matory- irritant,  the  bacteria — and  these  are  generally  pus  cocci — are 
taken  up  by  the  lymph  vessels,  and  then  they  spread  into  the  larger 
lymph  channels,  and  wherever  the  bacteria  become  lodged  they  give 
rise  to  inflammation  or  thrombosis.  Fischer  found  staphylococci  to  be 
the  most  frequent  cause  of  lymphangitis  (fifteen  times  in  eighteen 
cases).  In  two  cases  streptococci  were  present  alone,  and  in  one  case 
the  Bacterium,  coli  commune.  As  a  result  of  the  inflammation,  the 
walls  of  the  lymph  vessels  undergo  a  change,  the  endothelium  may 
perish,  and  the  entire  wall  may  necrose,  suppurate,  etc.  The  lymphan- 
gitis may  terminate  in  either  a  restitutio  ad  i7itegrum,  with  absorption 
of  the  exudate  and  regeneration  of  the  destroyed  endothelium,  or  in 
abscess  formation  and  necrosis  of  the  walls  of  the  lymph  vessels  and 
surrounding  parts.  Chronic  inflammation  of  the  lymph  vessels  leads 
to  hyperplasia  of  the  connective  tissue,  with  induration  of  the  lymph 
vessels  and  the  tissue  surrounding  them. 

Histological  and  Experimental  Investigations  upon  the  Movement  of  the 
Lymph  during  Inflammation. — The  lymphatic  system  plays  both  a  passive 
and  an  active  part  in  inflammation.  As  long  as  the  lymphatic  vessels  remain 
free  from  the  inflammatory  process  they  carry  off  the  products  of  the  in- 
flammation, the  emigrated  leucocytes,  and  red  blood-corpuscles,  and  the  in- 
flammatory process  may  resolve  without  going  on  to  the  formation  of  an 
abscess.  An  abscess  is  particularly  apt  to  develop  when  the  walls  of  the 
blood-  and  lymph- vessels  become  affected  to  a  marked  degree  by  the  inflam- 
matory agent,  causing  a  retardation  of  the  lymph  current  and  insufficient 
removal  of  the  inflammatory  products.     The  slowing  of  the  lymph  current 


334:  INFLAMMATION  AND  INJURIES. 

may  eventually  become  a  complete  stasis,  Avith  emigration  of  the  leucocytes 
from  the  lymph  channels  and  a  corresponding  infiltration  of  the  tissues,  re- 
sulting in  abscess  or  gangrene  of  the  affected  parts.  The  changes  which 
occur  in  lymph-vessels  during  inflammation  are  the  same  as  those  that  occur 
in  the  blood-vessels. 

Clinical  Course  of  Acute  Lymphangitis  and  Lymphadenitis. — Acute 
Ijniphaiigitis  presents  the  following  clinical  picture  :  After  the  reception 
of  a  wound  which  is  not  treated  aseptically,  possibly  a  superficial  abra- 
sion of  the  skin  on  the  fingers,  the  patient  complains  of  pain  in  his 
entire  arm,  particularly  when  it  is  moved.  When  the  patient  is  care- 
fully examined  there  will  usually  be  found  a  painful  swelling  of  the 
epitrochlear  and  axillary  glands,  and  from  the  still  visible  wound,  or 
from  the  site  where  it  existed,  there  will  be  seen  red  stripes  leading  up 
to  the  axilla.  There  Avill  ordinarily  be  fever  at  the  same  time.  The 
subsequent  course  of  the  disease  varies.  There  either  occurs,  when 
proper  treatment  is  adopted  (rest,  elevated  position,  ice),  a  complete 
restitutio  ad  integrum^  or  there  is  a  continuation  of  the  fever,  with  an 
increase  of  the  local  inflammatory  symptoms  leading  to  suppuration, 
generally  in  the  form  of  a  circumscribed  abscess,  e.  g.,  in  the  lymphatic 
glands  of  the  axilla  and  its  neighbourhood.  If  the  inflammation  in- 
volves the  more  deeply  lyiug  lymph  channels,  there  will  be  none  of 
the  above-mentioned  red  stripes  in  the  skin.  Acute  inflammation  may 
then  suddenly  appear  in  the  corresponding  lymphatic  glands,  which 
may  either  entirely  resolve  or  go  on  to  the  formation  of  an  abscess. 
Any  lymphangitis  is  capable  of  giving  rise  to  extensive  inflammation 
and  suppuration,  to  cellulitis,  erysipelas,  suppurative  periostitis,  gener- 
ally accompanied  by  superficial  necrosis  of  the  neighbouring  bone ; 
also  to  general  systemic  infection,  pyaemia,  or  septicaemia,  terminating 
in  death.  All  these  possibilities  depend  upon  the  nature  of  the  poison 
which  is  absorbed,  or  upon  the  virulence  of  the  bacteria.  Occasionally 
a  severe  phlegmon  (§  70)  or  a  general  systemic  poisoning — particu- 
larly pyaemia — makes  its  appearance  at  a  rather  late  period,  long  after 
the  lymphangitis  has  entirely  disappeared.  In  such  cases  the  bacteria, 
which  were  first  admitted  through  an  interruption  of  the  continuity  of 
the  skin,  lie  dormant  in  a  lymph  gland,  and  after  the  lapse  of  a  cer- 
tain length  of  time,  either  spontaneously  or  as  the  result  of  some  cause 
which  gives  rise  to  inflammation  (a  blow,  violent  muscular  movements, 
etc.),  they  may  suddenly  excite  dangerous  suppuration,  and  even  cause 
death  from  pyaemia  or  general  septic  poisoning  of  the  whole  system. 
The  study  of  the  clinical  course  of  lymphangitis,  caused  by  bacterial  in- 
fection, teaches  us  very  plainly  the  necessity  of  treating  with  antiseptic 
principles  even  the  most  insignificant  wound  on  the  surface  of  the  body. 


§69.]  ARTERITIS  AND  PHLEBITIS.  335 

The  Treatment  of  Acute  Lymphangitis  and  Lymphadenitis. — The  treat- 
ment of  acute  lymphangitis  and  lymphadenitis  in  fresh  cases  consists  in 
placing  the  affected  portion  of  the  body  in  a  proper  (elevated)  position 
and  giving  it  complete  rest.  For  lymphangitis  of  the  hand  the  arm 
should  be  fixed  in  the  vertical  position,  upon  Yolkmann's  suspension 
splint,  for  instance,  which  is  very  serviceable  for  this  purpose  (Fig.  202, 
page  209) ;  the  circulation  is  thus  regulated,  the  afferent  arterial  current 
is  checked,  while  the  efferent  current  in  the  veins  and  lymphatics  is 
made  to  flow  off  more  readily,  and  the  inflammatory  swelling  goes 
down,  usually  very  rapidly.  Ice  should  be  applied  in  combination  with 
the  elevated  position,  or,  if  cold  is  not  well  borne,  moist  applications 
covered  over  with  rubber  tissue  are  excellent.  In  addition,  grey  mer- 
curial ointment,  very  gently  rubbed  in,  serves  a  useful  purpose.  The 
course  of  the  disease  must  be  carefully  watched  for  the  appearance  of 
any  localised  redness  and  swelling  indicating  suppuration.  AYhenever 
suppuration  can  be  demonstrated  by  fluctuation,  the  pus  should  be  let 
out  by  incision  at  the  earliest  possible  moment.  Occasionally  there  will 
be  noticed  a  great  tendency  to  recurrence,  especially  after  infection  by 
cadaver  poisoning  (§  76),  and  this  recuriing  lymphangitis  requires  the 
most  careful  treatment.  In  such  cases  the  warm  baths  recommended  by 
Billroth  and  others  are  exceedingly  useful.  But  search  should  always 
be  carefully  made  for  the  possible  presence  of  some  focus  of  infection 
— some  small  wound,  ulcer,  pustule,  etc.— and  this,  when  found,  should 
be  treated  upon  antiseptic  principles. 

§  69.  Arteritis  and  Phlebitis.  Infiammation  of  the  Walls,  of  the 
Blood-vessels  {Arteritis^  Periarteritis^  Phlebitis^  PerijMehitis). — We 
referred  to  inflammation  of  the  walls  of  the  vessels  in  the  chapters  on 
inflammation  (§  56)  and  the  repair  of  wounds  (§  61),  We  saw  that  in 
every  inflammation  there  occurred  an  alteration  in  the  walls  of  the 
vessels,  and  that  in  every  injury  to  a  vessel  and  in  the  organisation  of 
the  thrombus  an  inflammation  took  place  for  the  purpose  of  forming  a 
cicatrix  in  the  vessel.  Every  reparative  process  which  takes  place  in 
a  wound,  even  though  aseptic  in  its  nature,  is  an  inflammatory  change  ; 
but  the  aseptic  repair  of  the  injured  vessels  in  a  wound  and  the  organ- 
isation of  the  thrombi  into  vascular  connective  tissue  take  place  with- 
out any  disturbance.  When  an  injury,  however,  becomes  infected  by 
bacteria,  the  inflammation  which  then  develops  in  the  walls  of  the 
vessels  becomes  a  matter  of  great  importance. 

We  shall  concern  ourselves  here  principally  with  the  inflammation 
of  the  walls  of  the  vessels  which  results  in  suppuration — acute  suppura- 
tive arteritis  and  phlebitis.  Both  of  these  inflammatory  jDrocesses  are 
very  apt  to  be  observed  in  conjunction  with  a  suppurating  wound  or 


336 


INFLAMMATION  AND  INJURIES. 


ulcer,  and  are  caused  by  micro-organisms,  particularly  those  micrococci 
which  excite  suppuration  (staphylococcus,  streptococcus,  etc.). 

The  suppurative  necrotic  arteritis  may  be  secondary  to  already  ex- 
isting disease  of  the  surrounding  tissues.  In  such  cases  the  intiamraa- 
tion  first  attacks  the  adventitia,  and  then  extends  to  the  inner  coats  of 
the  artery.  If  the  artery  contains  a  thrombus,  as  is  the  case  after  liga- 
tion, the  thrombus  may,  from  the  influence  of  the  bacteria  which  have 
entered  it,  undergo  a  suppurative  breaking  down  (thrombo-arteritis 
purulenta),  and  as  a  result  of  the  sloughing  of  the  arterial  wall  a 
haemorrhage  may  result  which  can  endanger  the  life  of  the  patient. 
In  other  cases  the  suppurative  thrombo-arteritis  is  developed  by  em- 
boli, which  carry  the  infectious  material  from  some  focus  of  infection 
into  the  blood-vessels,  and,  finding  lodgment  at  some  jjoint,  produce 
there  suppurative  changes  (metastatic  abscesses). 

In  suppurative  inflammation  of  the  veins  (phlebitis)  ^practically  the 
same  phenomena  are  observed.  It  is  caused  either  by  the  direct  en- 
trance of  bacteria  into  the  blood-vessels  or  by  the  extension  to  the  latter 

of  an  infectious  inflammation  in 
the  surrounding  parts ;  for  in- 
stance, an  acute  suppurative  in- 
flammation of  the  cellular  tissue 
may  extend  and  involve  the  walls 
of  a  vein.  The  inflammation  in 
the  wall  of  a  vein,  particularly  the 
alteration  which  it  produces  in 
^||N  the  intima,  the  endothelium,  gives 
rise  to  the  formation  of  a  throm- 
bus and  thrombo-phlebitis ;  or 
else  this  order  is  reversed,  and  the 
thrombus  forms  before  there  is  an 
inflammation  of  the  walls  of  the 
vein.  In  the  veins  thrombi  are 
particularly  liable  to  develop  in  the  region  of  the  valves  (Fig.  300), 
as  the  blood  current  flows  more  slowly  at  these  points  than  at  others, 
and  the  micro-organisms  can  thus  more  easily  find  lodgment  (Fig.  301). 
If  in  a  suppurative  thrombophlebitis  the  suppui-ating  masses  contain- 
ing micrococci  are  swept  off  in  the  blood  current  to  other  parts  of  the 
body,  wherever  they  are  deposited  they  form  the  above-mentioned 
metastatic  abscesses  resulting  in  pyaemia  (§  75).  Buday  maintains  that 
the  lodgment  of  emboli  made  up  of  large  particles  of  tissue  or  masses 
of  cocci  is  by  no  means  necessary  for  the  production  of  metastatic  sup- 
puration; the  micro-organisms  circulating  in  the  blood  may  become 


Fig.  300.— Thrombus 
in  the  valve  of  a 
vein  (schematic). 


Fig.  301.— Purulent 
thrombus  of  a  vein 
(schematic  I. 


§69.]  ARTERITIS  AND  PHLEBITIS.  337 

lodged  in  tlie  endothelium  of  the  vessels,  and,  growing  very  rapidly, 
break  through  their  walls  and  give  rise  to  phlebitis,  thrombosis,  and 
secondary  phlegmonous  processes.  From  what  has  just  been  said,  it 
follows  that  every  infection  of  the  blood  by  micro-organisms,  every 
suppurative  inflammation,  as  soon  as  it  extends  to  the  walls  of  a  vessel 
and  reaches  its  lumen,  is  an  exceedingly  grave  event  on  account  of  the 
spreading  of  the  pus,  or  rather  the  bacteria,  through  the  circulation. 

Other  inflammatory  conditions,  affecting  the  walls  of  the  vessels, 
which  concern  the  surgeon,  are  the  acute  inflammations  which  are 
particularly  liable  to  occur  in  the  intima  of  the  aorta  and  the  other 
arteries  in  pysemic  and  septic  infections  of  the  general  system,  and 
which  are  due  to  the  bacteria  or  the  products  of  their  metabolism 
circulating  in  the  blood.  Anatomically,  these  inflammations  are  char- 
acterised by  the  formation  of  groups  of  small  cells  in  the  intima  and 
the  other  coats  of  the  arteries,  and  by  a  fibrinous  exudation  into  the 
intima,  the  latter  being  sometimes  covered  by  a  tough  layer  of  fibrin. 

It  is  important  for  the  surgeon  to  bear  in  mind  that  the  acute  in- 
flamrriations  occurring  in  the  walls  of  the  vessels  in  conjunction  with 
injuries  to  the  soft  parts  are,  after  all,  only  partial  manifestations  of 
other  local  and  general  bacterial  infections,  such  as  a  circumscribed 
or  spreading  cellulitis,  erysipelas,  pygemia,  or  septicaemia.  We  shall 
therefore  abstain  from  going  into  the  diagnosis  and  treatment  of  in- 
flammation of  the  walls  of  the  vessels  separately  at  present,  as  this 
subject  will  be  brought  up  again  in  connection  with  the  diagnosis 
and  treatment  of  the  inflammations  or  infections  of  the  surrounding 
parts. 

The  phlebitis  and  the  periphlebitis  which  sometimes  occur  in  a  more 
or  less  isolated  form  like  a  lymphangitis,  and  often  originate  from  some 
insignificant  injury,  are  diagnosed  and  treated  briefly  as  follows :  The 
subcutaneous  veins  feel  like  cords  on  account  of  the  inflammatory 
thickening  of  their  walls  and  the  thrombosis  which  takes  place  in  their 
interior.  The  process  is  essentially  a  periphlebitis  with  inflammatory 
infiltration  of  the  sheaths  of  the  vessels,  and  the  veins  are  not  always 
thrombosed.  If,  however,  thrombi  do  exist  in  the  veins,  there  is  usu- 
ally a  corresponding  oedematous  swelling  from  the  disturbance  in  the 
circulation.  The  treatment,  particularly  when  the  disease  occurs  in 
the  lower  extremity — and  it  sometimes  occurs  spontaneously  in  individ- 
uals with  varicose  dilatation  of  the  veins — consists  in  placing  the  ex- 
tremity in  a  properly  elevated  position,  enveloping  it  in  a  moist  dress- 
ing covered  with  rubber  tissue,  and,  in  addition,  rubbing  in  mercurial 
ointment.  This  rubbing  in  or,  more  correctly,  inunction  of  mercurial 
ointment  for  phlebitis  must  be  done  with  the  greatest  caution  and  by 
23 


338  INFLAMMATION  AND   INJURIES. 

gentle  strokes  of  the  hand,  so  as  not  to  loosen  any  thrombi  and  liave 
them  carried  olf  into  the  general  circulation,  as  sudden  death  may 
result  from  cei-ebral  embohsm,  or  from  the  lodgment  of  an  embolus  in 
the  pulmonary  artery.  By  this  treatment  the  local  disease  and  the 
fever,  when  the  latter  exists,  are  caused  to  disappear  ;  the  cord- like 
veins  becoming  softer  after  the  lapse  of  about  six  to  eight  days,  and 
finally  assuming,  by  degrees,  a  perfectly  normal  character.  In  such 
cases  the  phlebitis  or  the  periphlebitis,  whether  there  has  been  a 
thrombus  formation  or  not,  resolves  to  a  complete  restitictio  ad  in- 
tegrum. If  an  abscess  develops,  the  pus  should  be  let  out  as  soon  as 
possible  by  an  incision.  A  permanent  occlusion  of  the  vessel  some- 
times follows  the  organisation  of  a  thrombus  in  a  vein  ;  this  is  particu- 
larly apt  to  happen  in  varicose  veins  of  the  leg.  The  so-called  phlebo- 
liths  (vein  stones)  result  from  calcification  of  venous  thrombi.  The 
manner  in  which  thrombi  develop,  and  the  changes  which  occur  in 
them,  have  been  described  on  pages  296-298. 

§  70.  CelMitis. — By  cellulitis  is  meant  an  inflammation  of  the  soft 
parts  which  has  a  tendency  to  go  on  to  suppuration,  and  is  particu- 
larly liable  to  be  located  in  the  subcutaneous  cellular  tissue,  or  more 
deeply  in  the  intermuscular  cellular  tissue,  or  beneath  fascia,  in  the 
sheaths  of  tendons,  in  the  periosteum,  etc.  We  distinguish  clinically 
two  principal  classes :  the  circumscribed  and  the  diffuse.  The  former 
remains  more  or  less  limited  to  the  neighbourhood  of  the  original  start- 
ing-point of  the  inflammation,  while  the  latter  has  a  marked  tendency 
to  spread  and  becomef  a  progressive  process,  the  worst  form  of  which 
is  the  very  acute  septic  phlegmon  ;  the  inflammation  sometimes  mani- 
fests a  tendency  to  spread  with  incredible  rapidity. 

It  is  not  always  plainly  visible  open  wounds,  or  large  recent  inju- 
ries, which  give  rise  to  the  cellulitis.  Often  enough  it  is  an  insignifi- 
cant, perhaps  already  healed,  abrasion  of  the  epidermis  near  the  nail, 
such  as  a  scratch  or  a  needle  prick,  which  forms  the  starting-point  for 
a  spreading  inflammation.  ISTot  infrequently,  the  cellulitis  develops  at 
some  spot  widely  removed  from  the  point  of  inoculation,  from  which 
the  bacteria  have  been  carried  off  in  the  lymph  channels,  finally  lodg- 
ing in  some  suitable  locality,  a  lymph  gland,  for  instance,  where  they 
grow  and  develop.  The  cellulitis  which  used  to  be  called  spontaneous 
in  its  origin  does  not  exist.  There  is  always  an  infection  by  bacteria, 
or  by  the  products  of  their  metabolism  {Staphylococcus  pyogenes  au- 
reus^ Streptococcus  pyogenes.,  the  bacillus  of  malignant  cedema,  less 
often  other  pus  cocci). 

The  Micro-organisms  found  in  the  Different  Forms  of  Cellulitis ;  Pus  Cocci. 

— Cellulitis  is  most  frequently  excited  Ijy  the  Staphylococcus  pyogenes  au- 


ro.] 


CELLULITIS. 


339 


reus  and  the  Streptococcus  pyogenes,  though  there  are  sometimes  found 
other  pus  cocci,  such  as  the  Staphylococcus  pyogenes  albus,  the  Micro- 
coccus pyogenes  tenuis,  the  Bacillus  pyogenes  foeticlus,  the  Bacillus  pyo- 
cyaneus,  etc.  (For  a  detailed  description  of  these  micro-organisms  see  pages 
328  and  330).  Occasionally  there  will  be  found  only  a  relatively  small  num- 
ber of  cocci  in  the  inflammatory  col- 
I  /«y^^^V  lections,  the  tissues  being  caused  to 


^ 


Fig.  302. — Streptococcus  of  progressive  tissue 
necrosis  in  mice  (Koch) :  a,  cells  of  the 
cartilage  in  the  ear ;  b,  streptococci,    x  YOO. 


.'•■;.'•:• 


•.V'        ..v» 


■/r^ 


Fig.  803. — Intermuscular  phlegmon  of  the 
forearm  ;  Streptococcus  pyogenes  between 
the  muscle  bundles  ;  stained  with  gentian 
violet  (after  Gram),     x  250. 


necrose  extensively  by  the  chemical  products  of  the  bacterial  metabolism 
(Fig.  302).  Again,  in  other  cases,  the  cocci  will  be  present  in  vast  numbers 
(Fig.  303).  The  cellulitis  excited  by  the  streptococcus  is  characterised  gen- 
erally by  a  marked  tendency  to  spread  with  great  rapidity. 

BacUlus  of  Malignant  (Edema.— The  worst  forms  of  cellulitis,  the  so- 
called  acute  malignant  oedema,  progressive  gangrenous  emphysema  (Piro- 
goff's  acute  purulent  oedema,  Maisonneuve's  gangrene  foudroyante),  are 
caused  by  different  anaerobic  bacilli  similar  in  appearance,  of  which  Koch's 
bacilli  of  malignant  oedema  are  the  most  constant.  These  little  rods  are 
probably  identical  with  the  vibrions  septiques  found  by  Pasteur  in  septi- 
caemia. In  man,  malignant  oedema  occurs,  for  instance,  in  conjunction  with 
a  compound  (open)  fracture  which  does  not  receive  aseptic  treatment,  or 
from  any  wound  not  aseptically  treated.  It  is  characterised  by  an  exten- 
sive emphysema  (evolution  of  gas)  and  by  decomposition  of  the  soft  parts, 
and  it  almost  always  terminates  in  death  after  the  lapse  of  a  few  days.  The 
bacilli  of  malignant  oedema  are  very  ajDt  to  be  found  in  the  superficial  strata 
of  garden  earth,  in  the  dust  collecting  in  the  cracks  of  a  floor,  in  all  sorts 
of  decomposing  matter,  in  dirty  water,  etc.  They  are  3.0  to  3. .5  fi  long  and 
about  1.0  /x  broad  ;  they  have  pointed  or  rounded  ends,  and  often  form  long 


34:0 


INFLAMMATION  AND   INJURIES. 


filaments  which  may  have  different  crooks  or  bends  (Fig.  305).  These  bacilli 
are  capable  of  very  active  movement,  and  possess  cilia  on  the  sides,  which 
can  be  demonstrated  by  means  of  Lottier's  metliod  of  staining.     Spores  make 

their  appearance  in  the  cultures  by  the  end  of 
the  first  day,  forming  best  at  a  temperature  of 
37°  C.  (98.6°  F.)  (body  temperature),  in  which 
they  grow  verj'  rapidly,  more  slowly  at  ordi- 
nary room  temperatures.  At  the  time  of  spore- 
formation  there  is  at  first  seen  a  slight  granular 
appearance  of  the  protoplasm,  and  then  the  for- 
mation of  a  central  oval  body  (Fig.  304,  6), 
which  is  not  stainable.  The  spores  are  set  free 
and  develop  into  ciliated  bacilli  (Fig.  304)  or 
threads  of  bacilli  (Fig.  305).  The  oedema  bacilli 
are  strictly  anaerobic,  and  can  only  be  culti- 
vated in  an  atmosphere  free  from  oxygen.  On 
gelatine  plates  the  colonies  form  small  shining 
knobs  containing  fluid,  and  the  gelatine  is  lique- 
fied. On  agar  plates  they  form  a  smokelike  cloudiness  with  an  ill-defined 
border.  Puncture  cultures  in  agar-agar,  to  which  should  be  added  one  to  two 
per  cent,  of  grape  sugar  or  sodium  sulphate  of  indigo,  develop  in  diffuse 
cloudy  groups  (Fig.  30(5).  Cultures  in  blood  serum  show  a  homogeneous 
cloudiness  in  the  line  of  the  puncture.  In  the  interior  of  the  boiled  potato 
the  bacilli  can  be  made  to  grow  at  a  temperature  of  38°  C.  (100.4°  F.),  and 
after  several  days  the  potato  will  be  found  riddled  with  a  network  of  bacilli. 
Kita.sato  found  that  when  the  bacilli  are  cultivated  in  guinea-pig  bouillon  in 
the  presence  of  hydrogen  the  fluid  becomes  cloudy,  and  then  in  two  to  three 
days  clears  again,  showing  the  pres- 


FiG.  304.— Bacillus  of  malisnaut 
cedema :  a,  bacillus  with  flagella 
(  X  1,000) ;  b,  spore  formation. 


ence  of  a  whitish  precipitate.  On 
opening  the  culture  a  foul,  pene- 
trating odour  is  given  off.  The 
bouillon  culture  remains  virulent 
for  months.  The  bacilli  can  be 
stained  by  all  the  aniline  dyes,  and 
will  then  frequently  itt-esent  a  gran- 
ular appearance.  Gram's  double 
stain  cannot  be  used.  If  0.1  to  0.3 
cubic  centimetres  of  a  bouillon  cul- 
ture is  injected  into  the  subcuta- 
neous tissue  of  mice  and  guinea- 
pigs,  the  animal  thus  inoculated 
will  die  in  eight  to  fifteen  hours. 

Upon  post-mortem  examination  there  will  be  found  stai'ting  from  the  point 
of  inoculation  an  extensive  subcutaneous  cedema,  the  fluid  of  which  it  con- 
sists being  of  a  reddish  colour  and  full  of  bacilli,  with  bubbles  of  gas  scat- 
tered here  and  there.  The  bacilli  will  be  found  located  principally  in  the 
serous  cavities  and  in  the  fluids  contained  in  the  different  organs.  Guinea- 
pigs  inoculated  with  the  peritoneal  fluid  taken  from  such  an  animal  will  die 
very  quickly.     The  bacilli  can  only  be  demonstrated  in  the  blood  several 


Fig.  305. — Bacilli  of  malignant  oidema  in  the  form 
of  lonjr  "threads. 


70.] 


CELLULITIS. 


341 


days  after  death.  If  bouillon  cultures  are  kept  for  ten  minutes  at  a  tempera- 
ture of  115°  C  (239°  F.),  or  if  they  are  filtered  first  through  porcelain,  and 
then  about  100  cubic  centimetres  of  the  fluid  rendered  germ-free  in  either 
"way  are  injected  at  three  successive  periods  into  the  perito- 
neal cavity  of  a  guinea-pig,  the  animal  will  be  rendered  im- 
mune from  subsequent  inoculations  with  the  bacilli  them- 
selves. In  other  words,  by  injecting  the  products  of  the 
metabolism  of  the  bacilli,  the  animals  can  be  made  unsuscep- 
tible to  the  bacilli. 

Septic  Emphysema  and  other  Processes  due  to  the  Bacillus 
Coli  Communis. — In  a  case  of  fatal  septic  emiDhysema  in  Gus- 
senbauer's  clinic,  Chiari  found  that  the  Bacillus  coli  com- 
munis was  the  cause  of  the  disease.  Chiari  attempted  to 
excite  a  disease  analogous  to  the  "  septic  emphysema "'  in  man 
with  its  gas  formation,  by  injecting  these  bacilli  into  animals, 
but  all  his  attempts  failed.  He  could  not  bring  about  gas 
formation,  though  he  made  intravenous,  intra]Deritoneal,  and 
subcutaneous  injections.  The  animals  died  from  septicaemia, 
and  the  bacilli  taken  from  their  dead  bodies  and  isolated  in 
pure  cultures  evolved  gas  in  considerable  quantities.  Bunge 
and  others  have  confirmed  this  observation  of  Chiari's.  The 
colon  bacillus  which  is  normally  present  in  the  mouth  and 
gastro-intestinal  canal  produces  extremely  poisonous  products 
of  metabolism  which  are  probably  destroyed  by  the  bile  (Gil- 
bert). It  is  of  very  variable  virulence.  Although  usually 
harmless,  it  may,  for  unknown  reasons,  take  on  a  high  grade 
of  virulence  and  give  rise  to  various  forms  of  inflammation, 
not  only  of  the  intestine  (enteritis,  dysentery,  appendicitis) 
and  its  vicinity  (peritonitis,  liver  abscess,  endometritis)  but 
also  in  distant  organs  (endocardium,  meninges,  thyroid  gland, 
lungs,  joints),  and  of  the  external  coverings  of  the  body. 
Other  micro-organisms,  such  as  streptococci,  are  sometimes 
present  at  the  same  time.  According  to  Park  the  Bacterium 
coli  commune,  which  occurs  in  different  forms,  is  probably  identical  with 
Emmerich's  Bacillus  necqoolitanus,  the  Bacillus  foetidus,  the  Bacillus 
lactis  aerogenes,  and  a  number  of  others. 

Frankel  obtained  from  four  cases  of  malignant  oedema  an  anaerobic  ba- 
cillus incapable  of  motion,  which  is  similar  to  the  anthrax  bacillus,  and  some- 
times occurs  in  the  form  of  threads  joined  together.  Subcutaneous  injections 
of  these  cultures  gave  rise  in  guinea-pigs  to  typical  malignant  oedema. 


Fig.  300.— Pure 
culture  of  the 
bacilli  of  ma- 
lignant cecle- 
ma.  Agar-in- 
di^o  -  sodium 
sulphate.  ■ 


Symptoms  of  a  Circumscribed  Cellulitis. — The  symptoms  of  a  more 
or  less  circumscribed  cellulitis  vary  with  the  latter's  situation ;  the 
more  superficial  the  inflammation  is,  the  plainer  are  the  manifestations 
of  the  beginning  cellulitis.  In  a  superficial  cellulitis,  involving  the 
skin  and  subcutaneous  cellular  tissue,  the  affected  skin  area  is  red  and 
swollen,  it  feels  hot,  and  is  painful  upon  pressure.  The  skin  is  tense 
with  oedema  and  cannot  be  lifted  from  the  underlying  parts.     The  in- 


342  INFLAMMATION  AND  INJURIES. 

filtration  feels  hard  at  first,  but  subsequently,  with  the  onset  of  suppu- 
ration, it  becomes  soft  and  doughy.  Resolution  of  the  inflammation 
without  suppuration  is  a  very  rare  occurrence.  AYlien  the  transition 
to  pus  has  taken  place,  when  an  abscess  is  present,  the  alfected  area 
fluctuates — i.  e.,  by  alternating  pressure  made  with  both  index  fingers, 
the  pus  is  caused  to  "  fluctuate "  or  take  on  a  wave  motion,  as  any 
fluid  will  do  when  set  in  motion  in  a  cavity  w4th  yielding  walls.  The 
pus  either  forces  its  way  to  the  surface  through  the  skin,  which  under- 
goes a  gradual  thinning  process,  or  it  is  evacuated  by  an  incision.  The 
longer  the  suppuration  is  allowed  to  continue  before  being  permitted  to 
escape  externally  the  more  apt  is  the  pus  to  burrow  or  extend  to  the 
parts  in  the  neighbourhood  of  the  abscess.  In  this  way  a  spreading 
cellulitis  dangerous  to  life  may  originate  from  a  circumscribed  cehu- 
litis  or  suppuration. 

If  a  circumscribed  cellulitis  is  deeply  situated  at  the  outset,  there 
is  but  little  change  in  the  skin,  and  neither  swelUng  nor  redness  will  be 
present,  and  only  when  the  deej)  process  draws  near  to  the  surface  of 
the  body  will  any  of  the  above-described  manifestations  of  its  presence 
be  revealed,  the  first  being  pain  on  pressure  with  oedema  and  redness 
of  the  skin. 

In  the  neighbourhood  of  the  circumscribed  celkilitis  there  will  be 
necrosis  of  the  skin,  and  particularly  of  the  fascia,  tendons,  tendon 
sheaths,  muscles,  and  bones,  in  proportion  to  the  amount  of  inflammatory 
infiltration  and  the  ensuing  suppurative  breaking  down.  This  death 
of  tissue  "will  be  the  more  easily  prevented  or  limited  the  earlier  incisions 
are  made,  and  the  cavity  washed  out  with  antiseptic  solutions  of  bi- 
chloride of  mercury  (1  to  1,000-2,000)  or  of  carbolic  acid  (three  per 
cent.).  Every  cellulitis  which  is  not  recognised  early  in  its  course  may 
not  only  lead  to  extensive  suppuration,  with  a  proportionate  destruction 
of  tissue,  but  may  even  cause  the  death  of  the  patient  from  a  fatal  gen- 
eral systemic  infection — pyaemia,  for  instance — if  the  inflammatory  ele- 
ments are  carried  off  and  spread  throughout  the  body  by  the  blood- 
vessels. Under  such  conditions  inflammation  of  the  lymph  channels 
(lymphangitis)  and  inflammation  of  the  a;rteries  and  veins  (arteritis, 
phlebitis)  may  be  excited,  with  the  formation  of  suppurating  thrombi  in 
the  veins,  also  swellings  and  abscesses  of  the  lymph  glands,  and  meta- 
static abscesses  in  the  internal  organs,  etc.  Accompanying  every  cir- 
cumscribed cellulitis  there  will  be  fever,  the  intensity  of  which  will 
vary  according  to  the  virulence  of  the  poison. 

Felon  or  Paronychia.— A  felon  is.  for  the  most  part,  at  the  outset  a  cir- 
cumscribed inflammation  of  the  subcutaneous  cellular  tissue  of  a  finger,  par- 
ticularly about  the  nail  and  on  the  palmar  aspect.     Paronychia  may  appear 


§  70.]  CELLULITIS.  343 

to  begin  spontaneously,  but  usually  results  from  some  injury,  which  may  be 
only  a  very  small  abrasion  of  the  epidermis.  It  is  most  apt  to  occur  in  indi- 
viduals who  are  constantly  receiving  superficial  injuries  of  the  skin  on  their 
fingers,  or  in  those  who,  like  physicians  and  anatomists,  frequently  handle 
decomposing  substances  and  thus  infect  themselves.  The  inflammation  is 
more  likely  to  spread  into  the  deeper  parts  than  to  come  to  the  surface  ;  but 
there  are  also  superficial  forms  of  paronychia  which  spread  very  rapidly. 
The  pain  is  usually  very  severe,  as  great  pressure  is  exerted  upon  the  nerves 
in  the  tense  tissues.  Death  of  tissue  is  a  common  occurrence  as  a  result  of 
the  closure  of  the  capillaries  and  small  veins  and  arteries  by  pressure.  If 
the  paronychia  extends  to  the  tendon  sheath,  it  usually  spreads  rapidly  on 
account  of  the  looseness  of  the  tissue.  From  a  neglected  felon  or  parony- 
chia, resulting  in  a  spreading  cellulitis,  many  a  patient  has  suffered  a  serious 
loss  of  function  of  the  hand,  or  the  hand  itself,  or  the  forearm,  or  the 
whole  arm,  while  the  lives  of  some  patients  have  not  been  saved  even  by  an 
amputation. 

Symptoms  of  the  Diffuse  Spreading  Cellulitis. — The  diffuse  spreading 
cellulitis,  formerly  called  diphtheritis  of  the  cell  alar  tissue,  is  usually 
very  acute  and  much  worse  than  the  circumscribed  variety.  Like  the 
latter,  it  is  sometimes  caused  by  very  trifling  injuries,  such  as  a  needle 
prick,  or  by  a  v^ound  of  the  soft  parts  of  a  bone,  or  of  a  joint,  which 
is  not  brought  soon  enough  under  the  protection  of  antiseptic  treat- 
ment. The  local  manifestations  are  at  the  outset  the  same  as  those  of 
a  circumscribed  cellulitis.  In  many  instances  the  disease  begins  with 
a  severe  chill  and  a  proportionately  high  fever.  The  changes  in  the 
overlying  skin  may  at  first  be  very  slight,  and  in  fact  it  is  not  even 
reddened  in  the  very  dangerous  deep  forms  of  cellulitis  which  spread 
very  rapidly.  Just  these  cases  are  the  ones  so  often  unrecognised  by 
the  beginner.  The  process  spreads  quickly  in  the  deep  subfascial  cellu- 
lar tissue,  and  may  terminate  in  a  relatively  short  time  in  a  fatal  sys- 
temic infection.  But  in  a  spreading  diffuse  cellulitis  the  skin  is  gen- 
erally involved,  and  has  a  dark  or  bluish-red  colour,  and  not  infrequently 
the  epidermis  is  elevated  by  blebs ;  there  is  also  an  inflammatory  in- 
filtration of  the  skin  which  may  make  it  as  hard  as  a  board.  If  the 
cellulitis  is  deeply  situated,  the  skin  feels  more  doughy  and  oedematous. 
The  pain  is  very  marked  and  usually  there  is  a  high  fever.  IN'ot  rarely 
the  course  of  the  disease  is  so  acute  that  even  after  the  expiration  of 
four  to  five  days  disarticulation  of  the  extremity  may  be  necessary,  or 
it  may  even  then  be  too  late  to  prevent  the  death  of  the  patient  from  the 
general  systemic  poisoning.  This  form  of  septic,  spi-eading  cellulitis  with 
high  fever,  extensive  gangrenous  destruction  of  tissue,  and  death  by 
general  systemic  poisoning,  has  a  very  unfavourable  prognosis,  and  has 
received  the  names  of  malignant  cedema,  progressive  gangrenous  em- 
physema, acute  purulent  oedema  (Pirogoif),  and  gangrene  foudroyante 


344  INFLAMMATION  AND  INJURIES. 

(Maisonnenve).     These  dangerous  forms  of  septic  cellulitis  are  excited 
bv  the  bacillus  described  on  page  339. 

If  the  diffuse  intlammatorj  infiltrate  in  the  subcutaneous  cellular 
tissue,  in  the  subfascial  and  intermuscular  tissue,  the  sheaths  of  the 
tendons,  and  in  the  periosteum,  is  changed  into  pus  and  softens,  the 
pain  decreases,  and  there  follows  an  extensive  necrosis  of  the  infijtrated 
tissues,  including  the  skin,  subcutaneous  cellular  tissue,  fascia,  muscles, 
tendons,  and  bone.  Large  sacs  are  formed  filled  with  pus,  the  skin 
is  lifted  from  the  underlying  parts,  and  joints  are  opened.  As  a  result 
of  the  decomposition  of  the  pus,  emphysema,  or  the  formation  of  gas, 
takes  place,  and  this  may  be  so  marked  that  a  j)eculiar  crackling  can 
be  obtained  on  palpation,  and  a  more  or  less  tympanitic  resonance  will 
be  elicited  on  percussion.  If  the  diffuse  celluHtis  does  not  carry  off  the 
patient  by  general  sepsis,  the  subsequent  course  of  the  disease  is  often 
very  tedious,  consisting  in  the  gradual  sloughing  away  of  the  gangre- 
nous parts,  and  the  proportionate  formation  of  cicatricial  contractures 
in  the  skin,  tendons,  muscles,  joints,  etc.  The  patient  may  also  die  in 
this  stage  from  pysemia,  marasmus,  parenchymatous  degeneration  of 
the  internal  organs,  or  from  extension  of  tlie  inflammation  to  vital 
parts — for  example,  from  the  skull  to  the  meninges.  Death  may  also 
result  from  hemorrhage  following  supjDurative  perforation  of  the 
arteries  or  large  veins,  etc. 

Prognosis  of  Cellulitis. — The  lyrognosis  of  cellulitis  varies  greatly,  de- 
pending upon  the  situation  of  the  disease,  the  extent  of  the  inflammation, 
and  the  kind  of  bacteria  which  excites  the  process.  A  cellulitis  of  the  scalp, 
for  instance,  is  a  serious  matter,  from  the  danger  of  the  inflammation  spread- 
ing to  the  cranial  cavity.  In  general,  the  superficial  forms  of  cellulitis  are 
not  dangerous,  while  tlae  deeper,  subfascial,  spreading  forms,  by  causing  gen- 
eral systemic  infection,  involve  the  greater  risk  to  life  the  longer  they  remain 
unrecognised.  The  Avorst  forms  are  those  with  progressive  emphysema, 
caused  by  infection  with  the  bacillus  of  malignant  cedema ;  they  often  ter- 
minate fatally  within  a  few  days,  before  the  local  manifestations  of  the  pro- 
cess become  plainly  marked.  The  prognosis  of  the  others  may  be  inferred 
from  what  has  been  said  of  them. 

Treatment  of  Cellulitis. — The  treatment  of  every  cellulitis  is  prac- 
tically the  same,  whether  the  inflammation  is  circumscribed  or  spread- 
ing. Much  time  used  to  be  lost  by  the  employment  of  poultices  to 
obtain  resolution  of  the  inflammation.  The  knife  should  be  used  as 
soon  as  possible,  and  free  incisions  made  to  diminish  the  inflammatory 
tension  of  the  tissues  and  to  allow  the  pus  to  escape.  "We  do  not  wait 
till  suppuration  and  breaking  down  of  the  tissues  have  taken  place, 
but  we  immediately  make  an  incision  into  the  region  where  there  is  the 
most  pain  or  the  most  pronounced  swelling  and  inflammatory  infiltra- 


§  70.]  CELLULITIS.  345 

tion,  even  ttLOugh  there  may  be  as  yet  no  pus  present.  If  early  inci- 
sions are  thus  made  it  may  be  possible  to  prevent  death  of  tissue  from 
taking  place,  particularly  in  the  tendon  sheaths,  bones,  etc.,  or  at  least 
to  limit  the  amount  of  it,  and  cases  treated  in  this  manner  will  heal 
comparatively  the  most  rapidly.  The  incisions  should  not  be  too  small ; 
it  is  better  to  make  them  too  free  rather  than  not  large  enough.  The 
collection  of  pus  should  be  laid  bare  throughout  its  whole  extent  by 
long  incisions,  and  any  pockets  that  may  be  present  opened  up.  If  the 
cellulitis  is  deep,  the  incision  should  be  carried  through  the  skin  and 
fascia  with  the  knife,  and  then  the  incision  should  be  deepened  with  a 
blunt  instrument — a  closed  dressing-forceps,  for  instance — down  to  the 
bone  if  necessary.  In  an  extensive  cellulitis  the  parts  which  appear 
sound  must  be  examined  very  carefully,  to  determine  whether  pus  may 
not  have  burrowed  into  or  beneath  them.  After  making  the  incisions 
the  region  in  which  there  have  been  large  collections  of  pus  should  be 
washed  out  vigorously  with  a  1  to  1,000  solution  of  bichloride  of  mer- 
cury, or  three  to  five  per  cent,  of  carbolic  acid.  Schimmelbusch  and 
others  have,  it  is  true,  proved  that  the  disinfection  of  infected  wounds 
accomplishes  very  little  or  nothing,  because  the  micro-organisms  enter 
the  interstices  of  the  tissues  very  quickly  and  are  thus  out  of  reach  of 
the  action  of  the  antiseptic  solutions.  Furthermore,  it  should  be  borne 
in  mind  that  all  bacteria  after  they  have  been  killed  have  a  pyogenic 
action  through  the  poisonous  protein  substances  that  are  set  free,  and 
upon  these  the  antiseptic  solutions  have  no  action.  If  infected  wound 
cavities,  abscesses,  etc.,  are  freely  opened  and  drained  the  pathogenic 
bacteria  which  are  mostly  obligate  or  facultative  anaerobic  are  so  hin- 
dered in  their  development  by  the  entrance  of  air  that  they  will  usually 
die  in  part  in  consequence  merely  of  the  incision  and  drainage.  Henle 
and  Messner  came  to  exactly  opposite  conclusions  to  those  of  Schim- 
melbusch, particukrly  if  they  used  cultures  of  not  too  great  virulence. 
According  to  them  a  general  infection  can  be  prevented  by  energetic 
disinfection  of  infected  wounds.  In  any  case  we  should  make  it  the 
rule  to  disinfect  infected  wounds  just  as  we  have  always  done,  and  thus 
conform  to  the  general  practice.  The  discharge  of  pus  is  provided  for 
by  the  use  of  drainage  tubes  or  gauze  packing.  The  best  dressing  for 
a  circumscribed  cellulitis  is  one  which  is  antiseptic  and  absorbent— for 
example,  iodoform  gauze,  sterilised  mull  and  cotton,  or  pads  of  moss, 
jute,  etc.  Of  course,  the  dressings  should  not  exert  any  more  than 
moderate  pressure,  to  prevent  pus  from  being  forced  into  the  connec- 
tive-tissue spaces.  In  cellulitis  of  the  fingers,  I  employ  wet  dressings 
of  1  per  cent,  acetate  of  aluminium  and  warm  antiseptic  baths,  and  then, 
later,  iodoform  and  boric  ointment.     Poultices,  which  used  to  be  so 


346  INFLAMMATION  AND  INJURIES. 

much  in  vogue,  should  he  condemned.  Their  use  has  caused  much 
harm.  To  he  ahle  to  determine  -svhether  there  is  any  burrowing  or  re- 
tention of  pus,  the  dressings  must  at  first  be  frequently  changed,  pos- 
sibly every  day,  or  every  second  or  third  day  ;  and  not  until  the  wound 
begins  to  granulate  and  suppuration  ceases  can  the  dressings  be  left 
undisturbed  for  a  longer  period.  If  the  suppuration  has  been  exten- 
sive, secondary  sutures  may  be  of  service  in  hastening  the  repair  after 
the  packing  has  been  removed. 

In  diffuse  cellulitis,  with  extensive  destruction  of  tissue,  long  in- 
cisions, followed  by  packing  the  wounds,  are  particularly  valuable,  and 
this  may  be  subsequently  supplemented  with  advantage  by  permanent 
irrigation  (pages  181,  182).  After  the  gangrenous  tissues  are  cast  off 
and  the  granulating  stage  has  begun,  a  return  may  be  made  to  anti- 
septic protective  dressings  of  iodoform,  dermatol,  etc.  To  shorten  the 
time  required  by  a  large  granulating  wound  to  become  covered  with 
skin,  Thiersch's  skin  grafts  are  very  useful  (see  §  42).  In  the  treat- 
ment of  every  cellulitis,  it  is  exceedingly  important  to  secure  for  the 
inflamed  part  a  proper  position  upon  splints  (§  53),  or  in  a  sling  (Fig. 
181),  etc.  Elevation  of  an  inflamed  lower  extremity,  or  vertical  sus- 
pension of  an  inflamed  hand,  has  an  excellent  effect,  and  sometimes 
works  wonders.  In  the  worst  cases  of  sej^tic  cellulitis,  amputation  or 
disarticulation  of  the  affected  extremity  will  sometimes  be  found  neces- 
sary in  order  to  save  the  life  of  the  patient.  Unfortunately,  the  operation 
is  sometimes  performed  too  late,  when  general  sepsis  is  already  present. 

The  after-treatment  of  the  sequelae  of  cellulitis,  the  cicatricial  con- 
tractures, necrosis  of  bone,  etc.,  is  conducted  on  the  lines  laid  down  for 
these  conditions  in  another  chapter  (Contractures,  Necrosis  of  Bones). 

Phlegmasia  Alba  Dolens,  or  "  milk  leg,"  is  an  inflammation  of  the  leg, 
rarely  of  both  legs,  running  a  slow  course,  -n-ith  oedema  and  pain,  principally 
due  to  venous  thrombosis  and  occuri'ing  mostly  in  lying-in  women  and  in 
cachectic  patients  (tuberculosis,  carcinoma,  etc.).  The  phlegmasia  alba  dolens 
of  puerperal  women  is  usually  caused  by  the  extension  of  an  infectious  in- 
flammation of  the  pelvic  connective  tissue  (parametritis),  which  ordinarily 
takes  place  in  the  second  week  after  confinement.  It  terminates  either  in 
absorption  of  the  inflammatory  infiltrate,  or  in  suppuration  or  gangrene, 
and  rarely  in  death,  which  is  then  apt  to  be  due  to  embolism  or  sepsis.  The 
phlegmasia  alba  dolens  of  cachexia  is  mainly  the  result  of  venous  stasis, 
caused  by  defective  cardiac  and  pulmonary  activity.  It  rarely  goes  on  to 
suppuration. 

§  71.  Erysipelas. — By  erysipelas  (from  epv6p6<;,  red,  and  iriWa,  skin) 
is  meant  a  spreading  inflammation  of  the  external  cutaneous  covering 
of  the  body,  or  rather  of  its  smaller  lymph  channels,  and  of  those  of 
the  subcutaneous  cellular  layer,  caused  by  bacteria  (streptococcus).     It 


§  71.]  ERYSIPELAS.  347 

is  a  S23ecifie  dermatitis,  characterised  (1)  by  a  more  or  less  rapid,  for 
the  most  part,  continuous  extension  along  the  surface,  less  often  into 
the  deeper  parts ;  (2)  by  a  toxic  diseased  state  of  the  general  system 
(intoxication  fevei")  going  hand  in  hand  with  the  local  inflammatory 
disease ;  and  (3)  generally  by  a  complete  restitutio  ad  integrum 
of  the  local  inflammation,  at  least  in  the  typical  and  uncomplicated 
cases.  Gangrenous  destructive  processes,  abscess  formation,  etc., 
take  place  in  exceptional  cases,  and  are  then  complications  of  the 
local  disease. 

Etiology  of  Erysipelas— Streptococcus  of  Erysipelas.— The  micro-organism 
of  erysipelas  is  generally  a  streptococcus  (Figs.  295,  296,  and  307)  which  was 
first  obtained  in  pure  cultures  by  Fehleisen.  If  man  or  animals  are  inocu- 
lated with  this  streptococcus  true  ei'ysipelas  will  result.  I  have  produced  in 
animals  (rabbits)  true  erysipelas  by  inoculating  them  with  the  contents  of 
erysipelas  blebs.  The  Streptococcus  erysvpelatis  is  found  almost  every- 
where, particularly  in  the  air  of  surgical  wards  (Eiselsberg). 

Tissues  affected  by  this  disease,  when  examined  by  the  microscope,  reveal 
the  erysipelas  coccus,  especially  in  the  lymph  spaces  of  the  skin  and  subcu- 
taneous cellular  tissue,  but  it  is  usually 
not  to  be  found   in  the   blood-vessels.  \v 

Not  infrequently  there   will  be   large  ■■■  ■•   ... 

groups    of    the    streptococcus    present.  '•.'•',■  .'.•''•.;•. 

Recent  investigations  have  demonstrat-        .^^  ^  "■-'■■••■""  -v 

ed  that  Fehleisen's  erysipelas  coccus  is  -•:.■!■;.••■.  __  ■•';  .  '-."..^ 

identical  with  the  Streptococcus  pyo-  ';■.•  v.;-;.; .  '■    ..  '■■%^, 

^e9?es  described  ou  page  329,  and  neither  "  "   •.,'■•.  Xj^v.. 

coccus  can  be  distinguished  from  the  iji..  '% 

other  in  any  way.     The  description  of  -  '\ 

the  erysipelas  coccus  is  given  on  page  ,? 

329  {Streptococcus  p)yogenes).  Suppu-  j,^^  SOT.-Erysipelas  cocci  in  two  lymph 
ration  and  abscess  occur  in  erysiiDelas,  vessels  of  the  skin,     x  700. 

in  all  probability,  when  the  strejjtococci 

develop  in  large  numbers  in  the  tissues  outside  of  the  lymph  channels,  or 
when  ihere  is  a  mixed  infection — in  other  words,  when  the  Staphylococcus 
pyogenes  aureus  or  other  pus  cocci  are  present  in  addition  to  the  Strepto- 
coccus pyogenes.  The  erysipelas  which  is  complicated  by  gangrenous  de- 
structive processes  is  also  probably  caused  by  a  mixed  infection.  Some  au- 
thorities claim  that  erysipelas  can  be  caused  by  staphylococci  and  typhoid 
bacilli.  These  are  sometimes,  without  doubt,  mixed  infections.  The  combi- 
nation of  the  streptococcus  and  typhoid  bacillus  is  said  to  be  particularly 
dangerous.  Erysipelas  may  accordingly  be  said  to  be  a  non-specific  disease. 
It  is  possible  to  differentiate  two  main  varieties  of  the  disease :  1,  the  true 
primary  erysipelas  caused  almost  exclusively  by  the  streptococcus ;  and,  2, 
the  less  common  secondary  erysipelas  that  occurs  in  the  course  of  infectious 
diseases,  and  is  caused  by  the  micro-organism  that  has  given  rise  to  the  dis- 
ease in  question.  Kaltenbach  and  others  have  made  the  interesting  observa- 
tion that  erysipelas  or  the  erysipelas  coccus  can  be  transmitted  from  the 


34:8  INFLAMMATION  AND  INJURIES. 

mother  to  the  foetus  in  ntero.  Bostroem  has  also  demonstrated  the  fact  that 
erysipelas  cocci  ma}'  enter  the  blood.  He  saw  an  acute  catarrhal  pneumonia 
develop  in  conjunction  with  a  facial  erysipelas,  and  after  death  the  lym- 
phatic vessels  in  the  lungs  were  found  filled  with  streptococci.  The  systemic 
intoxication,  the  fever  in  ei*ysipelas,  is,  in  the  main,  the  result  of  the  entrance 
into  the  circulation  of  the  metabolic  products  of  the  streptococci.  The  strep- 
tococci themselves  cannot,  as  a  rule,  be  demonstrated  in  the  blood. 

Erysipelas  of  Mucous  Membranes. — Erysipelatous  inflammations  occur 
not  only  in  the  external  cutaneous  coverings  of  the  body  but  also  in 
mucous  membranes,  especially  the  adjoining  mucous  membranes  of 
tlie  nose,  mouth,  and  their  adnexa,  the  trachea,  the  female  genital 
tract,  the  bladder  and  the  rectum.  A  cutaneous  erysipelas  may  have 
involved  these  mucous  membranes  in  its  course,  or,  on  the  other  hand, 
an  erysipelatous  inflammation  may  originate  in  the  mucous  membranes 
and  extend  from  them  to  the  skin  in  the  form  of  a  true  erysipelas. 

Erysipelas  is  a  true  infectious  disease  of  wounds — i.  e.,  it  originates 
from  some  interruption  of  continuity  which  may  be  of  the  most  insig- 
nificant character.  Erysipelas  does  not  originate  spontaneously  in  the 
sense  that  used  to  be  understood  by  the  term.  But  there  are  forms  of 
erysipelas — for  instance,  in  systemic  pysemic  poisoning — which  have  a 
metastatic  origin.  From  any  cellulitis  a  capillary  lymphangitis,  in 
other  words,  an  erysipelas,  may  begin  if  the  streptococci  find  lodg- 
ment and  undergo  subsequent  develo])ment  in  the  lymphatics  of  the 
skin  and  subcutaneous  cellular  tissue. 

Location  of  Erysipelas. — As  regards  the  localities  affected  by  ery- 
sipelas, it  occurs  most  frequently  upon  the  face,  often  starting  from 
some  superficial  abrasion  of  the  skin,  an  nicer  in  the  nose,  etc.  Some- 
times erysipelas  cases  occur  in  such  numbers  in  some  particular  locality 
or  in  some  hospital  that  the  disease  becomes  epidemic,  or,  rather,  en- 
demic. Like  every  infectious- wound  disease,  erysipelas  has  become 
less  common  since  the  general  use  of  antiseptic  methods,  and  by  strict 
asepsis  it  is  possible  to  absolutely  prevent  an  outbreak  of  erysipelas  in 
a  recent  non-infected  wound. 

Symptomatology  of  Erysipelas. — The  clinical  picture  of  true,  uncom- 
plicated, cutaneous  erysipelas  is  in  the  majority  of  instances  character- 
ised by  the  sudden  occurrence  of  a  rapidly  rising,  generally  severe 
febrile  movement  which  goes  hand  in  hand  with  the  erysipelatous  in- 
flammation of  the  skin.  Subsequently  there  is  just  as  rapid  a  defer- 
vescence, the  temperature  falling  to  the  normal  or  below  it  when  the 
local  erysipelatous  inflammation  approaches  its  termination. 

At  the  beginning  of  a  true  cutaneous  erysipelas  there  will  be  noted 
the  gradual  appearance  of  a  diffuse,  somewhat  elevated  reddening  of 


§  71.]  ERYSIPELAS.  349 

the  skin  in  immediate  proximity  to  some  small  or  large,  recent  or  old, 
granulating  or  ulcerated  wound  of  the  skin.  Frequently  no  wound  of 
the  skin  can  be  made  out  at  all ;  a  shght  cutaneous  abrasion  may  have 
already  healed.  In  other  cases  the  point  at  which  the  streptococci  of 
erysipelas  have  entered  may  be  found  in  some  adjoining  mucous  mem- 
brane or  in  some  widely  removed  region.  The  redness  is  at  the  outset 
apt  to  be  in  spots,  which  often  appear  as  though  the  lymphatic  network 
had  been  injected  with  some  red  material.  It  was  mentioned  before 
that  the  streptococci  of  erysipelas  spread  mainly  in  the  lymph  channels 
of  the  skin  and  subcutaneous  cellular  tissue.  The  original  spots  very 
soon  coalesce,  forming  an  even,  diffuse  redness.  Sometimes  the  redden- 
ing of  the  skin  may  start,  as  has  been  said,  at  a  greater  or  less  distance 
from  a  wound  or  interruption  of  continuity  in  the  epidermis,  and  under 
such  conditions  the  red  stripes  of  a  lymphangitis  will  connect  the 
wound,  on  the  fingers  or  toes,  for  instance,  with  the  commencing  red 
spot  on  the  arm  or  on  the  leg  or  thigh  (see  Lymphangitis,  §  68).  The 
erysipelatous  redness  and  swelling  extend  steadily  now  in  this  and  now 
in  that  direction ;  they  migrate,  and  may  involve  large  areas  of  skin, 
or  even  the  entire  body,  depending  upon  the  intensity  of  the  disease. 
The  areas  of  skin  first  affected  begin  to  turn  pale  again  after  the  lapse 
of  about  two  to  four  days,  and  sometimes  earlier.  In  the  regions 
where  the  skin  is  firmly  attached  to  the  underlying  parts,  to  the  bones 
or  fascia,  the  erysipelas  is  apt  to  come  to  a  standstill.  Erysipelas  gen- 
erally extends  progressively,  though  in  cases  of  rapid,  wandering  ery- 
sipelas the  disease  may  sometimes  skip  over  an  area  of  skin — for  in- 
stance, in  erysipelas  of  the  foot — a  large  erysipelatous  patch  may  sud- 
denly appear  in  the  region  of  the  knee  or  thigh,  and  then  soon  after- 
wards coalesce  with  the  patch  on  the  foot.  Under  these  conditions  the 
two  foci  of  erysipelas  are  usually  connected  by  red  stripes  (lymphangi- 
tis). Occasionally,  especially  when  occurring  as  a  complication  of 
pyaemia,  there  will  be  observed  the  so-called  erratic,  or,  better,  multiple 
erysipelas,  which  makes  its  appearance  by  metastasis  upon  different 
parts  of  the  body. 

The  erysipelatous  reddening  of  the  skin  ordinarily  exhibits  different 
tinges,  varying  from  a  bright  to  a  dark  red  colour.  In  weak  indi- 
viduals, or  when  complicating  pulmonary  or  cardiac  affections  (disturb- 
ances of  circulation),  or  just  before  death  or  as  the  first  stage  of  local 
death  of  tissue,  the  erysipelas  has  more  of  a  bluish  colour. 

If  there  are  gastric  complications,  or  if  occurring  in  drunkards,  the 
cutaneous  redness  occasionally  assumes  a  yellowish  shade. 

The  swelling  in  an  area  affected  by  erysipelas  is  usually  uniform, 
and  the  pain  in  the  majority  of  cases  is  slight,  but  is  increased  on 


350 


INFLAMMATION  AND  INJURIES. 


pressure  with  the  linger.  Wherever  tlie  skin  is  superimposed  upon 
distensible  loose  tissue  there  will  be  a  marked  erysipelatous  exudation, 
as  in  the  scrotum,  penis,  the  female  genitals,  the  eyelids,  or  the  lips. 
As  a  result  of  the  saturation  of  the  superficial  layers  of  the  cutis  with 
serum  during  the  course  of  an  erysipelas  there  will  often  develop 
smaller  or  larger  .blebs,  at  the  outset  containing  a  clear  serous  tluid, 
and  later,  for  the  most  part,  pus.  The  blebs,  as  a  usual  thing,  very 
soon  dry  up  and  form  crusts. 

The  extension  of  the  erysipelas  takes  place  now  from  this  and  now 
from  that  border ;  it  strides  forward  hke  a  fire ;  it  wanders,  and  hence 
the  name  erysipelas  migrans  or  ambulans.  For  several  days  the  ery- 
sipelas may  spread  in  some  particular  direction,  and  then  the  process 


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Fig.  308. — 1,  Temperature  curve  of  an  erysipelas  lasting  two  days  with  a  sudden  typical  fall  of 
temperature ;  2,  temperature  curve  of  an  erysipelas  with  temporary  fall  of  the  temperature 
followed  by  a  relapse  of  the  erysipelas ;  recovery. 


ceases  and  begins  to  spread  from  another  border.  It  acts  like  a  fire 
which  cannot  be  controlled  and  which  continues  to  burn  wherever 
there  is  food  for  it,  and  the  flame  may  suddenly  again  break  out  in  a 
region  where  it  seemed  quenched.  Pfleger  thinks  that  the  spread  of 
erysipelas  in  a  particular  direction  depends  upon  the  course  of  the 
linear  furrows  of  the  skin.  The  rapidity  with  which  the  erysipelatous 
inflammation  extends  varies  greatly,  moving  forward  sometimes  one  to 
two  centimetres  within  twenty -four  hours,  again  four  to  eight  or  fifteen 
to  twenty  centimetres  and  more.  Eventually,  in  the  great  majority  of 
cases,  the  inflammatory  redness  and  swelling  terminate  in  a  complete 
restitutio  ad  integrum  ;  but  suppuration  may  occasionally  take  place 
and  multiple  abscesses  may  form,  or  as  a  result  of  very  pronounced 
swelling  or  from  the  extension  of  the  disease  to  the  deeper  parts  the 


§  71.]  ERYSIPELAS.  351 

erysipelas  may  become  complicated  by  phlegmonous  changes,  with  ex- 
tensive or  limited  death  of  tissue  (erysipelas  phlegmonosum,  erysipelas 
gangrenosum).  A  process  the  reverse  of  this  sometimes  takes  place — 
i.  e.,  a  deep-spreading  cellulitis  may  come  to  the  surface  and  run  its 
course  as  an  erysipelas  of  the  skin.  It  has  already  been  stated  that  in 
the  complicated  cases  of  erysipelas  there  is  usually  a  mixed  infection, 
due  to  the  streptococcus  and  other  bacteria. 

The  general  constitutional  symptoms  correspond  to  the  intensity 
and  extent  of  the  local  process.  The  rise  of  temperature  begins,  as  a 
rule,  suddenly  and  rather  violently,  with  one  or  more  chills,  and  sub- 
sequently, when  the  erysipelas  ceases,  the  temperature  returns  to  the 
normal  with  equal  rapidity.  At  the  height  of  the  disease  the  tem- 
perature generally  rises  to  about  40°  C.  (104°  F.)  or  more,  and  in  ex- 
ceptional cases  it  may  reach  42°  C.  (107.6°  F.).  The  fever  may  have  either 
a  continuous,  a  remittent,  or  an  intermittent  type  (see  pages  307,  309). 
Yery  often  there  will  be  pronounced  gastric  symptoms ;  the  regions 
over  the  liver  and  stomach  are  tender  on  pressure,  there  is  total 
loss  of  appetite,  with  nausea  or  vomiting,  the  thirst  is  ordinarily  excess- 
ive, the  tongue  is  heavily  coated,  dry,  etc.  The  spleen  is  frequently 
much  swollen ;  sometimes  there  is  pain  in  the  region  of  the  kidneys, 
the  urine  is  generally  dark  coloured,  and  may  contain  albumen,  blood, 
bile  pigment,  and  micrococci,  and  its  quantity  is  diminished.  If  the 
erysipelas  has  a  fatal  termination,  death  is  either  the  result  of  the  gen- 
eral systemic  poisoning  by  the  products  of  the  metabolism  of  the 
bacteria,  or  it  is  caused  by  some  local  complication,  such  as  the  exten- 
sion of  the  erysipelas  to  some  vital  organ,  to  the  cranial  cavity,  for 
example.  Occasionally,  if  the  erysipelas  is  protracted  for  a  great  length 
of  time,  the  gradually  increasing  exhaustion  of  the  patient  may  be  the 
direct  cause  of  death,  which  may  take  place  suddenly  after  convales- 
cence has  begun. 

There  is  no  typical  duration  for  an  erysipelas,  and  recurrences 
are  very  common.  The  erysipelas  may  appear  to  have  come  to  an 
end  and  then  it  will  suddenly  start  up  again.  Its  duration  varies 
between  hours  and  weeks.  There  are  well-marked  cases  of  erysipelas 
lasting  twenty-four  hours,  and  even  a  less  time,  and  others  which  con- 
tinue for  a  week,  with  now  greater  and  now  less  intensity,  and  which 
may  eventually  involve  the  entire  body,  and  possibly  attack  the  same 
locality  several  times.  The  average  duration  of  erysipelas  amounts  to 
about  six  to  eight  to  ten  days,  but,  as  Billroth  says,  it  is,  as  a  general 
thing,  unusual  for  the  disease  to  continue  more  than  fourteen  days. 

Habitual  Erysipelas. — Many  individuals  are  subject  to  what  is  called 
habitual  erysipelas,  a  form  of  the  disease  recurring  more  or  less  period- 


352  INFLAMMATION  AND   INJURIES. 

icallv  upon  some  particular  portion  of  the  body,  most  commonly  the 
face,  and  resulting  verj  often  from  a  chronic  nasal  catarrh  which  is 
accompanied  by  ulceration.  These  recurrent  attacks  of  erysipelas  give 
rise  not  infrequently  to  chronic  thickening  of  the  skin  (pachydermia) 
of  the  affected  parts — e.  g.,  on  the  lower  extremity,  the  scrotum,  vulva, 
face,  etc. 

Complications  of  Erysipelas. — As  complications  of  erysipelas,  there  may 
be  marked  disturbances  of  the  central  nervous  system  due  to  the  high  fever 
or  general  systemic  poisoning,  particularly  in  an  erysipelas  of  the  head,  which 
gives  rise  to  meningitis.  When  the  latter  condition  arises,  there  will  be  at 
the  outset  veiy  marked  symi^toms  of  irritation,  headache,  vomiting,  delirium, 
stupor,  and  finally  convulsions.  Exceptionally,  even  when  convalescence 
has  begun,  and  after  the  erysipelas  and  the  fever  have  almost  completely 
vanished,  there  will  be  observed  in  excitable  persons  a  state  of  collapse  with 
delirium  of  a  more  or  less  maniacal  nature,  accompanied  by  illusions  and 
hallucinations  of  sight  and  hearing,  the  so-called  collapse  delirium.  This 
temporary  aberration  of  mind  lasts  usually  only  a  few  days.  More  rarely 
there  are  paralyses  of  the  periplieral  nerves  as  a  result  of  central  disturbance, 
or  from  peripheral  neuritis  caused  by  the  erysipelatous  inflammation.  Ley- 
den  and  Renvers  observed  an  ataxia  of  the  lower  extremities  which  lasted  a 
considerable  time  and  followed  the  extension  of  an  erysipelas  of  the  head  on 
to  the  back. 

The  most  important  of  the  local  complications  which  may  arise  are  sup- 
puration and  gangrene,  and  the  combination  with  an  inflammation  of  a 
phlegmonous  character.  The  number  of  multiple  ab.scesses  which  may 
make  their  appearance  in  the  stage  of  convalescence  is  comparatively  large 
— twenty  to  thirty  or  more.  Landouzy  saw  as  a  result  of  an  erysipelas  in- 
volving the  face,  hairy  portion  of  the  scalp,  the  neck  and  back,  sixty-nine 
abscesses,  and  some  of  them  in  areas  which  had  not  been  affected  by  the 
erysipelas.  Occasionally  the  suppui-ative  process  is  more  diffuse  in  its 
nature,  and  extends  inwards,  leading  to  suppuration  of  the  muscles,  tendon 
sheaths,  joints,  etc.  (erysipelas  phlegmonosumj.  The  erysipelatous  joint  sup- 
purations appear  either  at  the  outset  and  run  a  very  acute  course,  or  they 
first  make  their  appearance  dmnng  convalescence.  Mention  should  also  be 
made  of  phlebitis,  lymphadenitis,  and  abscesses  of  the  lymph  glands.  The 
lymph  glands  are  usually  swollen  at  an  early  stage  of  the  disease.  Gangre- 
nous processes  occurring  in  a  true  erysipelas  are  rare  and  generally  of  limited 
extent,  and  only  extensive  and  severe  when  the  erysipelas  is  complicated  by 
changes  of  a  phlegmonous  character  {E.  gangrenosum).  Among  the  other 
local  complications  which  may  arise,  those  affecting  the  eye  should  be 
included,  such  as  impaired  vision,  rarely  temporary  blindness,  panoph- 
thalmia with  atrophy  or  suppuration  of  the  eyeball,  particulai-ly  when 
a  facial  erysipelas  .spreads  to  the  cellular  tissue  of  the  orbit,  iritis,  ulcera- 
tive processes  of  the  cornea,  retinitis,  and  optic  neuritis  with  atrophy  of 
the  optic  nerves.  There  may  also  be  catarrhal  and  suppurative  processes 
affecting  the  ear,  inflammation  and  suppuration  of  the  parotid  gland,  dys- 
phagia, and  sometimes  changes  in  the  pharynx  simulating  diphtheria.  Occa- 
sionally an  inflammation  of  the  lungs  is  produced  (erysipelatous  pneumonia). 


§71.]  JERYSIPELAS.  353 

Pleurisy  and  cardiac  affections  (pericarditis,  endocarditis,  and  myocarditis) 
are  not  common.  Among  the  gastro-iutestinal  complications  which  may 
arise  are  ulcerations  oi  the  small  intestine,  and  transitory  hypersemia  of  the 
intestmal  mucous  membrane  accompanied  by  bloody:'  diarrhoea.  A  similar 
condition  may  occur  in  patients  who  have  received  burns,  and  I  have  seen  it 
in  conjunction  with  extensive  carbolic  eirythema  (see  page  158).  The  liver 
and  spleen  only  exceptionally  give  rise  to  complications.  Jaundice  due  to 
gastritis  may  occasionally  be  present,  but  ha^matogenous  jaundice  can  also 
occur  in  severe  cases  of  erysipelas  as  a  result  of  the  poisoning  of  the  blood 
by  the  products  of  the  bacterial  metabolism,  and  this  is  usually  a  precursor 
of  speedy  death.  Nephritis  is  often  present  as  a  complication,  but  it  is  gen- 
erally of  a  temporary  nature ;  only  in  very  exceptional  cases  is  the  acute 
erysipelatous  nephritis  so  marked  as  to  cause  uraemia.  The  latter  is  particu- 
larly dangerous  when  occurring  in  individuals  already  affected  by  kidney 
disease  before  they  were  attacked  by  erysipelas.  Erysipelas  is  sometimes 
complicated  by  pyaemia  and  septicaemia  (see  §§74  and  75),  and  occasionally, 
as  has  been  stated,  erysipelas  will  occur  in  the  course  of  a  pygemia." 

Behaviour  of  the  Wound  in  Erysipelas.— The  interruption  of  continuity 
from  which  the  erysipelas  has  sprung  seldom  manifests  any  complications. 
The  healing  of  the  wound  per  lyrimam  intentionem  is  not  often  disturbed ; 
but  the  healing  may  sometimes  be  only  apparent,  and  the  wound  may  only 
unite  superficially,  while  in  its  deeper  parts  there  will  be  a  retention  of  the 
secretion  or  of  pus.  A  granulating  wound  will  often  exhibit  a  dry  or  dirty 
appearance,  and  may  be  covered  by  a  peculiar  croupous  diiDhtheritic  mem- 
brane. Erysipelas  has  occasionally  been  complicated  by  hospital  gangrene 
(§  72),  especially  before  antise^jsis  was  introduced. 

The  Curative  Effect  of  Erysipelas. — Great  interest  attaches  to  tlie 
influence  exerted  by  an  intercurrent  erysipelas  of  the  skin  upon  new 
growths,  particularly  those  of  a  lupoid  or  syphilitic  nature,  with-  or 
without  ulceration,  and  also  upon  tumours,  such  as  sarcoma  and 
carcinoma.  It  has  been  noticed  that  the  above-mentioned  forma- 
tions may  permanently  •  disappear,  and  that  ulcers  of  long  standing 
and  chronic  skin  diseases,  which  resisted  every  kind  of  treatment, 
have  improved  and  w^ere  healed  after  an  erysipelas  had  passed  over 
them.  The  French  have  given  the  appropriate  name  of  erysipeJe 
salutaire  to  an  erysipelas  which  acts  in  this  way,  and  numerous  obser- 
vations are  recorded  in  literature  upon  the  healing  powers  of  erysipelas 
for  all  sorts  of  diseases.  W.  Busch,  in  particular,  has  recorded  some 
very  remarkable  facts  relating  to  the  curative  eifect  of  erysipelas  upon 
large  tumours  (sarcomata,  lymphosarcomata),  and  he  showed  that  the 
tumours  underwent  a  rapid  and  extensive  fatty  metamorphosis,  and 
could  thus  be  absorbed  and  completely  disappear.  The  curative 
power  of  erysipelas  over  tumours  has  been  repeatedly  made  use  of 
artificially  for  the  purpose  of  destroying  inoperable  new  growths.  If 
inoculation  of  erysipelas  is  to  be  practised  on  any  patient,  it  must  be 
24 


354:  INFLAMMATION   AND   INJURIES. 

borne  in  mind  that  the  course  of  this  disease  cannot  always  be  held 
under  control,  and  that  there  is  a  possibility  of  a  fatal  termination,  as 
many  cases  testify.  And  altliough  it  is  certainly  justiiiable  to  produce 
erysipelas  artificially  for  the  purpose  of  curing  an  inoperable  tumour, 
the  patient  should  always  be  informed  beforehand  of  the  danger  of 
the  treatment.  P.  Bruns  has  recently  made  a  critical  investigation  of 
the  curative  effects  of  erysipelas  upon  tumours,  and  succeeded  in  col- 
lecting twenty-two  cases  from  literature.  There  was  a  complete  and 
permanent  cure  in  three  cases  of  sarcoma,  in  two  cicatricial  keloids, 
and  in  a  few  lymphomata.  In  Bruns's  own  case  a  perfect  recovery 
was  brought  about  from  a  recurrent  melano-sarcoma  of  the  breast. 
In  one  case,  observed  by  Janicke  and  Wisser,  in  which  erysipelas  inoc- 
ulation was  practised  for  an  inoperable  carcinoma  of  the  bi'east,  it 
could  be  demonstrated  with  the  microscopp  that  the  erysipelas  cocci 
actually  destroyed  the  cancer  cells.  Consequently  it  is  possible  for 
erysipelas  to  cure  a  carcinoma. 

Ferret  observed  the  complete  absorption  within  six  days  of  the 
callus  surrounding  an  already  united  fracture  of  the  thigh,  so  that  the 
fragments  again  became  as  freely  movable  as  at  the  time  of  fracture. 
There  is  one  other  curious  fact  ascertained  by  Emmerich,  Pawlowsky, 
and  Di  Mattel  which  should  be  mentioned  in  this  connection.  If  rab- 
bits and  guinea-pigs  are  inoculated  with  erysipelas,  during  the  ensuing 
three  to  ten  days  they  w^ill  be  unsusceptible  to  (immune  from)  anthrax  ; 
but  after  the  lapse  of  this  period  the  system  is  so  weakened  by  its  con- 
flict with  the  erysipelas  cocci  that  when  the  animal  is  infected  by  anthrax 
for  the  second  time  it  succumbs  more  easily  and  rapidly  than  it  normally 
would ;  in  other  words,  after  the  lapse  of  this  period  the  animal  is  no 
longer  immune  from  anthrax.  Quite  recently  a  germ-free  serum  has 
been  prepared  from  the  blood  of  sheep  infected  with  eiysipelas  cocci 
and  used  as  a  curative  remedy  for  anthrax,  malignant  tumours,  tuber- 
culosis, glanders,  and  syphilis.  It  is  impossible  at  present  to  give  an 
accurate  opinion  regarding  the  value  of  this  serum,  but  the  reports  that 
have  been  thus  far  made  are  not  very  encouraging. 

Erysipelatous  Inflammations  of  the  Mucous  Membranes. — Inflamma- 
tions analogous  to  cutaneous  erysipelas  occur,  as  has  been  stated,  in 
the  mucous  membranes  which  adjoin  the  skin,  and  consequently  in  the 
oral  cavity  and  its  aduexa  (nose,  pharynx,  larynx),  the  female  genital 
tract,  the  bladder,  and  the  rectum.  Erysipelatous  wandering  pneu- 
monia is  described  in  books  on  internal  medicine. 

Diagnosis  of  Erysipelas.—  The  diagnosis  of  the  ordinary  cutaneous  ery- 
sipelas is  very  simple  in  typical  cases,  and  can  hardly  cause  any  trouble. 
The  gradually  spreading  local  redness  and  swelling  of  the  skin  and  the 


§  71.]  ERYSIPELAS.  355 

accompanying  fever  are  so  characteristic  that  there  can  scarcely  be  any  con- 
fusion, even  with  the  exanthemata.  Erythema  bears  the  closest  resemblance 
to  erysipelas,  but  in  erythema  there  is  usually  no  fever,  and  the  swelling- and 
pain  are  not  nearly  so  pronounced  as  in  erysipelas. 

Prognosis. — In  general,  the  prognosis  of  erysipelas  is  not  unfavourable, 
but  in  no  case  of  this  disease,  no  matter  how  mild  it  may  seem,  can  we  be 
certain  of  a  satisfactory  termination.  There  are  many  circumstances  which 
affect  the  prognosis  of  an  erysipelas,  particularly  its  location,  the  constitution 
and  age  of  the  patient,  the  complications  which  may  arise,  the  intensity  and 
duration  of  the  local  disease,  and  of  the  fever,  etc.  The  more  extensive  the 
inflammation  the  higher  the  fever,  and  the  longer  it  lasts  so  much  the  worse 
is  the  prognosis.  The  mortality  given  by  various  authors  differs  very  much, 
the  average  being  about  eleven  per  cent. 

Treatment  of  Erysipelas. — A  great  number  of  remedies  have  been 
employed  for  erysipelas,  and  the  fact  that  the  treatment  varies  so  much 
shows  that  noth'ng  is  entirely  satisfactory  ;  and  it  is  my  opinion  that,  as 
yet,  we  have  no  very  reliable  and  effective  method  of  treatment.  Since 
the  disease  has  no  typical  duration,  it  is  very  natural  that  mistakes 
should  be  made  in  regard  to  the  curative  power  of  this  or  that  remedy. 

The  best  way  of  preventing  erysipelas  consists  in  treating  every  in- 
terruption of  continuity,  whether  recent  or  old,  large  or  small,  upon 
antiseptic  or  aseptic  principles  ;  and  whenever  a  dressing  is  changed  it 
should  be  done  with  a  careful  observance  of  the  rules  of  antisepsis. 
Erysipelas  is  never  seen  to  start  from  a  wound  that  has  been  made  in 
the  course  of  a  strictly  aseptic  operation.  When  the  erysipelas  has 
broken  out,  the  treatment  should  be  directed  against  the  general  febrile 
disturbance  and  the  local  disease.  The  treatment  of  the  fever  nas 
been  discussed  in  §  62. 

The  treatment  of  the  local  disease  consists  in  placing  the  affected 
portion  of  the  body  in  a  suitable  position.  Ice  is  employed  chiefly  in 
erysipelas  of  the  head.  Numerous  remedies  are  used  to  combat  the 
erysipelatous  inflammation.  At  the  outset  of  the  disease  parenchyma- 
tous injections  of  2  to  3  per  cent,  carbolic  acid  at  the  margin  of  the 
inflammation  are  to  be  recommended.  The  contents  of  three  to  five 
hypodermic  syringes  are  injected  along  the  advancing  edge  of  the  in- 
flamed and  through  the  sound  skin,  and  these  injections  are  repeated 
once  or  twice,  depending  upon  the  acuteness  or  rapidity  of  spread  of 
the  inflammation.  In  the  same  way  subcutaneous  injections  of  bichlo- 
ride, salicylic  acid,  cocaine,  ergotin  (5  to  8  centigrammes  in  alcohol  and 
glycerine  equal  parts)  have  been  employed. 

Estlander  recommends  subcutaneous  injections  of  morphine,  par- 
ticularly when  combined  with  a  daily  painting  of  the  diseased  area 
with  tincture  of  iodine.     Liicke  and  others  have  used  inunctions  of 


356  INFLAMMATION  AND  INJURIES. 

turpentine  with  success;  it  is  rubbed  into  the  diseased  area  of  skin  two 
to  three  to  five  times  a  day  with  a  brush  or  piece  of  cotton.  Strong 
tincture  of  iodine  can  be  appUed  with  a  brush  seven  to  eight  times  a 
day  ;  nitrate  of  silver  (one  to  four,  or  eight,  or  ten)  is  highly  praised  ; 
also  the  application  of  comj^resses  wet  in  a  three-  to  five-per-cent.  solu- 
tion of  carbolic  acid,  or  in  a  five-  to  ten-per-cent.  solution  of  trichlorphe- 
nol ;  fifty  to  eighty  per  cent,  resorcin  ointment  may  be  spread  over  the 
affected  part,  etc.  Another  method  is  to  rub  the  inflamed  area  vigor- 
ously with  absolute  alcohol  and  then  apply  cotton  saturated  Math  the 
same.  This  is  done  every  half  hour  during  the  first  twenty-four  hours, 
and  later  every  three  to  four  hours.  Heppel  recommends  painting  the 
borders  of  the  erysipelatous  area  with  a  ten-per-cent.  alcoholic  solu- 
tion of  carl)olic  acid,  covering  a  portion  of  skin  about  two  inches  wide 
all  around  the  diseased  spot.  The  following  methods  have  also  been 
recommended  for  treating  the  disease  locally :  Covering  the  erysipel- 
atous area  of  skin  with  ammonium  sulpho-ichthyolicum  mixed  with 
equal  parts  of  lard,  or  with  ichthyol  and  vaseline  (equal  parts),  and 
placing  over  this  absorbent  cotton ;  covering  the  erysipelatous  area 
close  up  to  the  surrounding  healthy  skin  with  an  ointment  of  one  part 
creolin,  four  of  iodoform,  and  ten  of  lanoline  (Koch  and  Mracek),  or 
with  white  lead,  or  with  a  varnish  of  linseed  oil,  over  which  some 
water-tight  material  is  applied,  etc.  Kiihnast,  from  his  experiments 
in  Kraske's  clinic,  recommends  nmltiple  scarifications  and  incisions, 
followed  by  irrigation  with. a  five-per-cent.  solution  of  carbolic  acid; 
also  the  application  to  the  erysipelatous  area  of  compresses  wet  with  a 
two-and-a-half-per-cent.  solution  of  carbolic  acid,  the  compresses  to  be 
changed  once  or  twice  a  day.  Riedel  and  Classen  recommend  scari- 
fication, particularly  at  the  advancing  margins  of  the  erysipelas.  Scari- 
fications are  exceedingly  effective,  especially  when  made  chiefly  or 
exclusively  in  the  healthy  adjoining  skin.  Madelung,  W.  Meyer,  and 
others  have  obtained  satisfactory  results  from  scarification  and  appli- 
cation of  compresses  wet  in  a  three-  to  five-per-cent.  solution  of  car- 
bolic acid  or  in  a  1  to  1,000-3,000  solution  of  bichloride  of  mercury. 
This  latter  method  of  treatment  is  coming  more  and  more  into  favour 
at  present.  Larrey  preferred  to  make  linear  or  punctate  cauterisa- 
tions with  the  red-hot  iron,  aiming  at  retaining  the  erysipelas  within 
the  barriers  made  by  the  eschars.  Wolfler  has  prevented  the  spread 
of  an  erysipelas  by  means  of  the  mechanical  compression  produced  by 
placing  strips  of  adhesive  plaster  along  its  borders.  For  the  same 
purpose  Xiehans  employed  collodion,  applying  the  latter  around  an 
extremity  over  a  space  about  two  handbreadths  in  width,  thus  encircling 
the  extremity  with  the  collodion  as  with  a  bandage.     Kroell  recom- 


§  71.]  ERYSIPELAS.  357 

mends  strips  of  caoutchouc  for  the  same  purpose.  Winiwarter  and 
Fraipont  speak  well  of  the  following  method  of  treatment :  The  part 
affected  bj  the  erysipelas  and  the  wound  are  soaked  for  ten  minutes 
in  a  bath  of  1  to  3,000  bichloride,  or  the  latter  is  used  in  the  form  of 
an  irrigation  for  a  longer  period  of  time  ;  the  erysipelatous  area  is  then 
dried,  and  it  and  the  adjoining  healthy  skin  are  covered  with  tar,  over 
which  is  applied  a  dressing  wet  with  Burow's  solution  (see  page  162)  ; 
then  iodoform  gauze  which  has  been  dipped  in  a  bichloride  solution 
is  placed  on  the  wound,  and  the  whole  dressing  is  bandaged  lightly  in 
position. 

It  has  been  attempted  to  combat  the  erysipelatous  inflammation  by 
the  internal  administration  of  drugs.  English  surgeons,  in  particular, 
give  iron  internally  (liq.  ferri  chlosat.,  in  large  doses,  fifteen  to  twenty 
drops  every  hour,  or  even  2.0  grammes  or  more) ;  others  use  liq.  ferri 
sesquichlorati.,  ten  to  fifteen  drops  every  two  to  three  hours  ;  ergotine, 
iodide  of  potassium,  and  belladonna  have  been  used  for  the  same  piu-- 
pose.  Haberkorn  has  recently  employed  with  success  benzoate  of 
sodium  in  mucilaginous  solutions,  or  in  some  effervescing  water,  in 
doses  of  fifteen  to  twenty  grammes  a  day ;  no  local  treatment  is 
made  use  of.  The  effectiveness  of  all  internal  medication  is  exceed- 
ingly doubtful.  Camphor  (internally  or  in  the  form  of  subcutaneous 
injections)  has  but  little  value,  though  it  was  highly  recommended  by 
Pirogoif. 

The  treatment  of  the  complications,  particularly  the  abscesses,  gan- 
grenous processes,  and  the  inflammations  of  joints,  should  be  con- 
ducted on  the  principles  laid  down  for  these  conditions.  At  the  time 
of  the  outbreak  of  the  erysipelas,  or  when  the  case  is  met  with  in  a 
later  stage,  the  wound  from  which  the  disease  starts  should  be  care- 
fully examined  and  treated  antiseptically,  and  if  any  blood  or  pus 
is  held  in  retention  it  should  be  let  out  by  removing  a  few  sutures, 
by  separating  the  agglutinated  margins  of  the  wound,  by  making  in- 
cisions, etc. 

If  it  is  desired  to  inoculate  an  erysipelas  for  therapeutic  purposes 
upon  an  inoperable  tumour  or  diseases  of  the  skin,  it  should  always 
be  borne  in  mind  that  infection  by  the  streptococcus  of  erysipelas  may 
cause  the  death  of  the  patient. 

Zoonotic  Erysipelas— Wandering  Erythema  {Erythema  migrans).— The 
so-called  erysipeloid  or  wandering  erythema  occurs  almost  exclusively  on 
the  hands,  and  attacks  most  commonly  individuals  who  handle  all  sorts  of 
dead  animal  substances,  dealers  in  game  or  fish,  cooks,  restaurant  keepers, 
butchers,  tanners,  oyster  openers,  and  those  who  come  much  in  contact  with 
cheese,  herring,  etc.     Erysipeloid  is  a  disease  of  wounds  which  is  not  very 


358  INFLAMMATION  AND  INJURIES. 

infectious  in  character,  and  aflfects  the  liands  almost  exclusively,  some  in- 
fectious substance  being  inoculated  into  small  wounds.  After  inoculation 
there  ensues  a  moderate  infiltration  of  the  skin,  giving  the  latter  a  dark -red 
discolouration  ;  there  is  no  fever,  and  the  disease  spreads  very  slowly,  with 
an  itching,  prickling  sensation,  and  it  may  take  eight  days  to  extend,  for  in- 
stance, from  the  finger  tip  to  the  metacarpus.  Tlie  reddening  of  the  skin 
more  often  occurs  in  spots ;  less  frequently  it  is  of  a  diffuse  character.  It  is 
only  very  exceptionally  that  the  erysipeloid  extends  as  far  as  the  wrist,  and 
it  never  reaches  the  forearm.  The  disease  is  often  very  stubborn  and  per- 
sistent, lasting  sometimes  three  to  four  to  six  weeks  unless  proper  treatment 
is  adopted  ;  but  in  other  cases  it  may  disappear  spontaneously  in  one  to  two 
to  three  weeks.  Eosenbach  found  that  a  coccus-like  body  was  the  cause  of 
the  erysipeloid  ;  it  is  larger  than  the  staphylococcus,  grows  best  in  gelatine 
at  a  temperature  of  20°  C,  forms  twisted  filaments  of  varying  length,  and 
bears  a  remarkable  resemblance  to  a  form  of  microbe  described  by  Colin 
under  the  name  of  cladothrix  dichotoma.  Roseubach  and  Cordua  have  pro- 
duced this  erysipeloid  by  inoculations  practised  on  themselves. 

Tlie  best  method  of  treating  the  zoonotic  erysipeloid  consists  in  cutaneous 
injections  of  a  three-per-cent.  solution  of  carbolic  acid  into  the  inflamed  area 
of  skin,  and  into  the  healthy  skin  immediately  adjoining  its  outer  borders. 

§  72.  Hospital  Gangrene — Wound  Diphtheria. — Hospital  gangrene 
{GangrcBna  nosocomialis)^  or  wound  diphtheria,  used  to  be,  in  the  pre- 
antiseptic  era,  a  very  common  disease,  particularly  in  hospitals  with 
bad  hygienic  arrangements,  and  in  military  practice,  but  if  antiseptic 
treatment  is  used  it  never  occurs.  Hospital  gangrene  is  a  local  wound 
disease,  always  bacterial  in  its  origin,  and  consists  essentially  of  a 
gangrenous  destruction  of  the  granulations  and  adjoining  tissues. 

Etiology  of  Hospital  Gangrene. — The  micro-organism  of  hospital 
gangrene  has  not  as  yet  been  discovered.  Rosenbach,  in  his  last  mono- 
graph on  hospital  gangrene,  could  give  no  information  upon  the  ex- 
citing cause  of  the  disease.  The  identity  of  hospital  gangrene  and 
diphtheria  is  still  an  open  question,  and  many  arguments  ^>/'6»  and 
con  have  been  advanced  by  different  authors.  W.  Roser  and  Eo- 
senbach have  been  the  most  outspoken  against  the  identity  of  the 
two  diseases.  Brunner  understands  by  wound  diphtheria  that  kind 
of  infection  of  wounds  which  is  caused  by  the  Loffler  bacillus, 
the  excitant  of  ordinary  diphtheria.  This  sometimes  occurs  in  the 
tracheotomy  wound  in  diphtheritic  stenosis  of  the  larynx,  and  also 
occurs  as  an  independent  infection  on  different  parts  of  the  body  with- 
out diphtheria  of  the  fauces.  Such  wounds  have  an  ulcerative  char- 
acter, and  besides  the  Loffler  bacillus  there  are  usually  pus  cocci 
present  (staphylococcus  and  streptococcus).  Wound  diphtheria  does 
not,  however,  correspond  with  true  hospital  gangrene  in  its  severe 
forms.     The  latter  are  practically  never  observed  since  the  period  of 


§  73.]  HOSPITAL   GANGRENE— WOUND   DIPHTHERIA.  359 

antiseptic  surgery,  and  hence  it  can  be  understood  whv  the  specific 
cause  of  true  hospital  gangrene  is  unknown  to  us.  Hospital  gangrene 
is  probably  a  marked  putrefaction  of  the  wound  caused  by  a  number 
of  micro-organisms.  The  pathological  changes  in  hospital  gangrene, 
like  those  in  diphtheria  of  the  pharynx,  consist  in  an  infarct  of  the  in- 
fected wound,  or  in  a  coagulation  necrosis,  as  it  is  called  by  Cohnheim 
and  Weigert,  in  which  are  present  great  numbers  of  micrococci  and 
bacteria  of  decomposition. 

Clinical  Cause  of  Hospital  Gangrene. — Clinically  the  disease  occurs  in 
one  of  three  forms  :  1,  The  superficial  croupous  and  diphtheritic  ;  2,  the 
ulcerative  diphtheritic,  and,  3,  the  pulpy,  the  latter  being  the  most  ma- 
lignant form.  These  different  forms  of  the  disease  may  run  into  each 
other,  and  clinically  cannot  always  be  sharply  distinguished.  The 
croupous  or  diphtheritic  form  of  hospital  gangrene  is  characterised  by 
the  development  of  hsemorrhagic  foci  accompanied  by  swelling,  the  foci 
subsequently  breaking  down  and  forming  a  foul,  suppurating,  jelly-like 
mass.  By  immediate  treatment  of  the  diphtheritic  area  "vvith  a  concen- 
trated chloride-of-zinc  solution,  or  with  the  Paquelin  thermo-cautery, 
the  spread  of  this  lowest  grade  of  hospital  gangrene  can  generally 
be  arrested.  The  ulcerative  form  of  the  disease  also  begms  with  the 
development  of  hsemorrhagic  spots  having  a  grey  or  greyish-yellow 
colour,  and  at  the  outset  is  of  limited  extent ;  but  in  a  relatively  short 
space  of  time  it  spreads  over  the  granulating  surface  and  changes  the 
latter  into  a  grey  or  greyish-yellow  mass,  which  subsequently  breaks 
down  into  a  gangrenous  pulp.  This  gangrenous  destruction  of  tissue 
may  steadily  advance  inwards,  and  superficially  may  involve  the  skin 
adjoining  the  granulating  surface  by  a  sj)reading  of  the  ulcerative  pro- 
cess. The  ulcerative  form  of  hospital  gangrene  may  change  into  the 
pulpy  or  most  dangerous  kind  of  wound  diphtheria.  In  the  pulpy 
form,  according  to  Konig,  there  occurs,  as  a  general  rule,  a  rapid  swell- 
ing of  the  tissues  in  consequence  of  the  extensive  hEemorrhages  into 
the  granulations,  followed  by  putrefaction  of  the  entii-e  mass  and 
the  evolution  of  gases  of  decomposition.  The  borders  of  the  wound 
are  red  and  very  painful.  The  swollen,  grey,  or  greyish-red  wound 
looks,  as  Konig  says,  like  a  soft,  decomposing  spleen  or  mass  of  brain 
tissue. 

The  course  of  hospital  gangrene  depends,  in  general,  upon  whether 
the  gangrene  of  the  wound  remains  superficial  or  extends  into  the  more 
deeply  lying  parts.  Every  form  of  hospital  gangrene  may  destroy  the 
skin  and  spread  into  the  subjacent  tissues,  particularly  if  it  is  of  the 
pulpy  variety.  The  gangrenous  changes  advance  very  rapidly,  and 
within  twenty-four  hours  cause  the  wound  to  become  double  its  origi- 


360  INFLAMMATION  AND   INJURIES. 

mil  size,  or  even  larger,  but  in  other  cases  the  chauges  take  a  much 
lunger  time. 

The  general  symptoms  correspond  to  the  severity  of  the  local  dis- 
ease. The  fever  may  be  continuous  or  remittent,  with  intercurrent 
chills.  Very  frequently  the  local  disease  begins  with  a  rigour  and  a 
fever  of  40°' to  41°  C.  (h)V  to  105.8°  F.). 

Prognosis  of  Hospital  Gangrene. — The  prognosis  of  hospital  gangrene 
depends  upon  the  form  of  the  gangrene  and  the  nature  of  the  treat- 
ment. The  pulpy  form  of  hospital  gangrene  has  the  most  unfavour- 
able prognosis  of  all.  The  strength  of  the  patient  and  the  conditions 
under  whitjh  he  has  lived  must  be  taken  into  account.  The  m.ilder 
forms  of  hospital  gangrene  will  often  get  well  spontaneously,  while  the 
more  severe  forms  will  frequently  cause  death  by  general  septic  poi- 
soning, unless  the  spread  of  the  gangrenous  process  is  combated  suffi- 
ciently early  and  energetically  by  proper  treatment.  Recurrences  of 
the  disease  take  place  not  infrequently. 

Treatment  of  Hospital  Gangrene. — The  treatment  of  hospital  gan- 
grene consists  in  the  energetic  use  of  the  Paquelin  thermo-cautery  and 
of  caustics,  particularly  nitric  acid  or  chloride  of  zinc,  to  check  the 
spread  of  the  gangrene.  Deeply  placed  gangrenous  foci  must  be  laid 
open  with  the  knife,  to  permit  the  pus  to  escape  and  to  enal)le  the  sup- 
purating region  to  be  energetically  disinfected  with  a  1  to  1,000  solu- 
tion of  bichloride  of  mercury.  Iodoform  or  naphthaline  are  excellent- 
substances  to  apply  in  the  dressings ;  or,  if  the  gangrene  is  very  exten- 
sive, antiseptic  irrigation  may  be  practised,  as  described  on  pages  ISl 
and  182.  If  it  becomes  necessary  to  amputate  a  gangrenous  limb,  the 
operation  should  be  performed  with  the  strictest  antiseptic  precautions, 
after  first  energetically  disinfecting  the  gangrenous  focus,  or  burning 
it  with  the  Paquelin  thermo-cautery  and  covering  it  with  an  antiseptic 
dressing  wet  with  bichloride. 

Every  patient  with  wound  diphtheria  should  be  isolated  with  the 
greatest  possible  care,  as  a  protective  measure  for  the  other  patients. 
Hospital  gangrene,  as  has  been  said,  does  not  occur  at  present  with 
the  antiseptic  method  of  treating  wounds ;  but  in  the  time  of  war, 
where  the  rules  of  antisepsis  cannot  always  be  strictly  observed,  hos- 
pital gangrene  is  likely  to  make  its  appearance. 

§  73.  Traumatic  Tetanus. — Tetanus  is  an  infectious-wound  disease 
characterised  by  cramp-like  corutractions  of  the  muscles  of  the  lower  jaw 
alone  (trismus),  or  by  contractions  of  certain  other  groups  of  muscles, 
or  of  the  muscles  of  the  whole  body  (tetanus).  The  tetanic  contractions 
often  begin  in  the  muscles  in  the  vicinity  of  the  injury  where  the  poison 
was  inoculated,  and  later  tetanic  spasms  of  the  other  muscles  follow. 


§73.]  TRAUMATIC  TETANUS.  361 

Etiology  of  Tetanus. — The  etiology  of  tetanus  has  been  recently  ad- 
vanced by  ]^icolaier,  Brieger,  and  particularly  Kitasato.  There  used 
to  be  a  great  many  theories  concerning  the  nature  and  etiology  of 
tetanus,  but  they  did  not  account  satisfactorily  for  its  occurrence  in  the 
injured,  and  they  are  to  be  looked  upon  at  present  as  untenable.  The 
recent  investigations  of  ISTicolaier,  Brieger,  and  Kitasato  have  proved 
beyond  a  doubt  that  tetanus  is  produced  by  a  specific  bacillus  dis- 
covered by  Kicolaier,  and  first  obtained  in  pure  cultures  by  Kitasato 
(Fig.  309). 

The  injuries  which  may  be  followed  by  tetanus  ai-e  of  every  de- 
scription.    Sometimes  they  are  severe,  and  involve  both  soft  parts  and 
bones,  such  as  compound  fractures,  and 
sometimes   less  severe,  such  as   burns,  . 

frost-bites,  or  insignificant    wounds   of  ^x  f 

the  skin  or  a  granulating  surface,  or  per-  M  y 

haps  only  a  small  punctured  wound,  etc.  /  . 

Tetanus  has  been  known  to  come  from  ^^    *»  /  K 

a  blister  and  the  sting  of  a  bee.    We  can      .  ^      \ 

easily  understand,  from  the  analogous  V^"\.-^  y  \ 

origin  of   other   infectious-wound   dis-        ^v  ^  V  \<^^  <^ 

eases,  particularly  anthrax,  how  tetanus  ^   '%j^    '        ^\ 

may  follow  the  very  slightest  interrup-  \  ,     _^ 

tion  of  continuity  in  the  skin.    The  dis- 

,      ,  ^    ^  "  Fig.    309. — Tetanus    bacilli   containinff- 

ease  is  particularly  apt  to  occur  as  a  re-         spores,  from  an  agar  culture.    X  1.000. 

suit  of  injuries  to  the  hands  or  feet,  in 

which  are  lodged  foreign  bodies,  such  as  bits  of  earth  or  splinters  of 
wood.  Animals,  such  as  horses,  may  often  be  the  means  of  transmit- 
ting the  tetanus  bacillus  to  man.  Occasionally  the  disease  appears  to 
break  out  after  the  lapse  of  a  certain  period  of  incubation,  and  conse- 
quently it  is  possible  for  tetanus  to  occur  after  the  wound  has  entirely 
healed.  The  disease  may  become  endemic  under  certain  conditions — 
for  instance,  in  hospitals  where  the  rules  of  antisepsis  and  asepsis  are 
not  strictly  observed. 

Experimental  Inoculation  of  Tetanus. — Carle,  Eattone,  Rosenbach,  and  a 
number  of  others  have  inoculated  animals — e.  g.,  guinea-pigs — with  tetanus 
from  human  subjects,  and  then  inoculated  othersanimals  from  the  first  ones. 
Nicolaier  performed  some  very  interesting-  experiments  in  Flugge's  labora- 
tory. While  carefully  studying  the  micro-organisms  in  surface  soil,  he  was 
surprised  to  find  that  a  disease  similar  to  human  tetanus  was  produced  in  a 
considerable  number  of  cases  (sixty-nine  times  in  one  hundred  and  forty 
experimental  inoculations)  by  inoculating  animals  with  earth  taken  from 
widely  separated  sources  (Berlin,  Wiesbaden.  Leipsic,  and  Gottingen).  The 
inoculations  with  the  earth  were  practised  at  the  root  of  the  tail  in  white 


362  INFLAMMATION  AND  INJURIES. 

and  yellow  mice,  and  beneath  the  skin  in  rabbits  and  guinea-pigs.  In  mice, 
after  the  lapse  of  one  and  a  half  to  two  and  a  half  daj's,  or  four  to  five  days 
in  rabbits,  cramps  occurred  in  the  muscles  in  the  neighbourhood  of  the 
region  inoculated,  and  later  the  tetanus  extended  to  the  muscles  of  the  other 
extremities  and  to  those  of  the  back  and  the  nape  of  the  neck.  In  rabbits, 
the  muscles  of  the  jaw  became  rigid  in  a  state  of  tonic  spasm,  and  death 
occurred  after  the  lapse  of  one  and  a  half  to  two  days.  Mice  died  twelve  to 
twenty  hours  after  the  first  symptoms  of  poisoning  made  their  appearance. 
Dogs  did  not  react  at  all  when  inoculated. 

The  post-mortem  examination  revealed,  as  in  man,  very  little  which  was 
distinctive.  Microscopically,  in  the  slight  amount  of  pus  at  the  point  of  in- 
oculation, micrococci  were  found,  and  particularly  a  peculiar  bristle-shaped 
rod  carrying  spores.  Nicolaier  was  not  able  to  obtain  pure  cultures  of  this 
bacillus ;  he  could  not  separate  them  from  other  bacilli,  and  consequently  it 
was  believed  that  tetanus  was  caused  by  a  kind  of  symbiosis  of  dijfferent  bac- 
teria. When  the  earth  was  heated  for  an  hour  the  inoculations  were  unsuc- 
cessful. Attempts  at  producing  infection  by  pus  taken  from  animals  at  the 
point  where  they  were  inoculated  succeeded  in  sixty-four  out  of  eighty-eight 
experiments,  the  disease  running  a  more  rapid  course  than  when  earth  was 
employed.  Inoculations  with  pieces  of  the  infected  tissues  succeeded  only 
fourteen  times  in  fifty -two  cases. 

Socin  has  also  excited  true  tetanus  by  making  inoculations  with  garden 
earth.  I  saw  one  fatal  case  of  tetanus  following  a  compound  fracture  which 
had  become  befouled  with  earth.  The  patient  came  under  my  care  after 
well-marked  tetanus  had  developed. 

Description  of  the  Tetanus  Bacillus. — Kitasato  was  the  first  to  isolate 
Nicolaiers  tetanus  bacillus  from  the  other  bacteria  found  accompanying  it ; 
he  cultivated  it  and  excited  tetanus  in  animals  by  inoculating  them  with  the 
pure  culture,  and  thus  established  the  correctness  of  the  suppositions  which 
had  existed  about  the  disease.  Kitasato  placed  in  the  necessary  culture 
medium  a  small  piece  of  tissue  taken  from  the  immediate  neighbourhood  of 
a  suppurating  wound  in  a  man  who  had  died  of  tetanus.  The  cultm-e  when 
placed  in  the  incubator  revealed  a  luxuriant  growth  of  bacteria ;  but  the 
kind  which  carried  spores  at  one  extremity  developed  the  most  rapidly, 
while  the  others  only  began  to  grow  after  the  lapse  of  a  certain  length  of 
time.  Before  these  latter  could  develop  Kitasato  heated  the  mixed  culture 
to  a  temperature  of  80°  C.  and  destroyed  all  the  bacilli  which  had  not  taken 
on  their  permanent  form,  leaving  only  those  which  were  capable  of  forming 
spores.  From  these  he  made  a  pure  culture,  which,  when  inoculated  upon 
animals,  established  the  fact  that  the  bacillus  containing  spores  in  one  of 
its  extremities,  and  first  discovered  by  Nicolaier.  was  actually  the  true 
bacillus  of  tetanus. 

Pathogenesis  of  Tetanus.— The  tetanus  bacillus  CFig.  309)  is  often  present 
in  the  surface  layer  of  ordinary  earth,  in  decaying  masonry,  decomposing 
fluids,  manure,  or  splinters  of  wood  found  in  wounds,  and  in  the  pus  from 
wounds  on  persons  who  have  died  of  tetanus.  It  is  a  slender  rod  with  distinct 
motility,  and  forms  spores  in  artificial  cultures  at  a  high  temperature.  These 
spores  are  found  at  one  end  of  the  bacillus,  and  give  it  the  familiar  drum- 
stick shape.     The  bacilli  collect  usually  in  irregular  groups,  and  sometimes 


73.] 


TRAUMATIC  TETANUS. 


363 


grow  into  long  filaments,  upon  which  the  divisions  between  the  segments  are 
almost  indistinguishable.  The  bacillus  grows  very  slowly,  best  at  a  tem- 
perature of  36°  to  38°  C,  while  below  16°  C.  no  development  takes  place.  It  is 
obligate  anaerobic — i.  e.,  it  grows  only  when  atmospheric  air 
is  absent.  In  the  presence  of  oxygen  the  bacillus  quickly 
died.  In  an  atmosphere  of  pure  hydrogen,  small  ray-like 
colonies  develop  slowly  upon  gelatine  plates  after  the  lapse 
of  some  days ;  they  liquefy  the  nutritive  medium  with  the 
evolution  of  gas,  and  present  an  appearance  similar  to  the 
hay  bacillus  (a  rather  thick,  solid  centre,  with  radiating  fila- 
ments). Stab  cultures  in  a  test  tube  containing  a  consider- 
able amount  of  grape-sugar  gelatine,  or  in  gelatine  to  which 
has  been  added  0.1  per  cent,  of  indigo-sulphate  of  sodium, 
give  a  culture  at  the  bottom  of  the  tube  having  the  appear- 
ance illustrated  in  Fig.  810.  At  the  end  of  the  first  week  it 
looks  something  like  a  fir-tree — i.  e.,  numerous  fine  processes 
radiate  outwards  from  the  line  of  puncture,  simulating  the 
Bacillus  figurans.  Subsequently  the  gelatine  surrounding 
the  colony  is  liquefied,  and  there  is  an  evolution  of  gas.  In 
a  test  tube  containing  agar,  to  which  has  been  added  one  to 
two  per  cent,  of  grape  sugar  or  indigo-sulphate  of  sodium, 
the  gi'owth  at  the  proper  incubation  temperature  is  more 
rapid  and  luxuriant,  and  after  the  first  or  second  twenty- 
four  hours  the  culture  causes  an  evolution  of  gas  which  has 
a  characteristic  unpleasant  odour.  In  grape-sugar  bouillon 
the  growth  of  the  culture  is  exceedingly  vigorous,  and  is  ac- 
companied by  the  formation  of  a  large  amount  of  gas.  In 
blood  serum,  at  a  temperature  of  34°  to  38°  C,  after  the  lapse 
of  one  to  three  days  small  round  cavities  develop,  which 
gradually  coalesce. 

Spore  formation,  at  a  temperature  of  37°  C,  takes  place  in  twenty  hours, 
and  occurs  at  one  end  of  the  bacillus,  this  portion  of  the  cell  swelling,  and 
giving  it  the  appearance  of  a  drum-stick  (Fig.  309).  The  spores  have  great 
vitality,  and  will  remain  alive  when  exposed  in  a  moist  state  to  a  tempera- 
ture of  80°  C.  for  one  hour,  but  are  destroyed  in  five  minutes  when  exposed 
to  steam  at  a  temperature  of  100°  C.  Dried  pus  containing  spores  retains  its 
virulence  after  the  expiration  of  sixteen  months.  The  tetanus  bacillus  is 
readily  stained  by  the  ordinary  aniline  dyes.  Gram's  method  can  also  be 
employed. 

If  a  small  amount  of  a  pure  culture  is  inoculated  upon  mice,  rats,  guinea- 
pigs,  or  rabbits,  the  first  kind  will  manifest  the  first  symptoms  of  the  disease  in 
twenty  to  twenty-four  hours,  the  last  in  two  to  three  days.  If  horses,  sheep, 
or  dogs  are  inoculated  with  the  pure  culture  they  will  develop  typical  tetanus. 
The  manifestations  of  the  disease  are  at  first  local,  and  confined  to  the  parts 
immediately  adjoining  the  point  of  infection,  from  which  they  gradually 
spread,  and  the  animal  then  dies  in  a  short  time.  At  the  point  of  infection 
there  is  infiltration  of  the  tissues  and  hypera^mia,  but  no  suppuration,  and 
sometimes  it  may  be  possible  to  demonstrate  the  presence  of  the  bacilli ;  but 
they  are  never  found  in  the  different  organs  or  in  the  blood.     The  most 


Fig.  310.  —  Teta- 
nus culture.  Stab 
culture  in  gela- 
tine with  indi- 
go -  sulphate  of 
sodium.  Seven 
days  old. 


364  INFLAMMATION   AND   INJURIES. 

typical  picture  of  tetanus,  usually  with  rapidly  fatal  outcome,  is  obtained  by 
injecting  subcutaneously  the  germ-free  filtrate  of  bouillon  cultures  of  the 
tetanus  bacilli.  Th3  period  of  incubation  is  longer  and  death  takes  place 
later  when  material  contiiining  the  bacillus  is  inoculated.  Tetanus  bacilli 
produce  their  harmful  action  not  by  multiplication  of  the  bacilli  within  the 
body  but  by  the  formation  of  very  poisonous  products  of  metabolism.  The 
toxines  produced  by  the  bacilli  have  an  action  similar  to  strychnine.  Many 
authorities  have  attempted  to  isolate  the  tetanus  toxine.  Weyl,  Kitasato,  and 
Brieger  obtained  a  highly  poisonous  substance  closely  allied  to  the  albumi- 
noid bodies  (tetanotoxalbumen).  which  gives  rise  to  tetanus  in  animals  after 
a  certain  period  of  incubation,  but  in  not  so  tj-pical  a  form  as  after  infection 
with  the  tetanus  bacilli  or  injection  of  sterilised  cultui-es. 

According  to  Courmont  and  Doyon,  the  tetanus  bacilli  form  at  first  a 
soluble  non-poisonous  ferment  by  which  the  real  tetanus  poison  is  pi-oduced 
at  the  expense  of  the  organism.  Several  poisonous  bodies  are  perhaps 
foi-med  during  the  incubation  period.  Brieger  obtained  some  time  ago  four 
toxines  in  a  pure  state,  viz.,  tetanine  C13H30N2O4,  tetanotoxine  CsHuN,  spas- 
mbtoxine,  and  a  toxine  hydrochlorate.  Very  small  amounts  of  these  toxines 
produced  in  animals  tetanic  symptoms,  but  not  typical  tetanus. 

I  The  Tetanus  Poison. — The  tetanus  poison  is  found  in  the  serum  of  the 
blood,  and  after  passing  through  the  blood  is  excreted  by  the  kidneys,  caus- 
ing the  latter  to  become  toxic.  Bruschetini  caused  tetanus  by  subcutaneous 
injections  of  the  urine  of  animals  infected  with  tetanus.  Buschke  and 
Oergel  found  drops  of  fat  almost  constantly  in  the  blood  of  the  animals  ex- 
perimented with.  The  liver,  spleen,  and  muscles  also  contain  a  very  poison- 
ous toxalbumen  that  kills  small  animals  immediately.  The  toxines  that  are 
formed  by  the  tetanus  bacillus  at  the  point  of  entrance  are  taken  up  partly 
by  the  lymph  channels  and  remain  for  a  certain  length  of  time  in  the  re- 
gionary  Ij'mph  glands  (Biidinger)  ;  others  act  directly  from  their  place  of 
formation  upon  the  peripheral  nerves,  and  are  probably  transmitted  in  the 
latter  directly  to  the  spinal  cord.  This  explains  the  development  of  the  local 
tetanus  at  the  place  of  inoculation,  and  then  later  the  general  tetanus.  The 
investigations  of  Brunner  and  others  have  given  us  more  exact  details  of  the 
mode  of  action  of  the  tetanus  poison  upon  the  nervous  system.  It  is  claimed 
that  the  poison  enters  into  chemical  composition  with  the  nerve  substance  of 
the  central  nervous  system,  or  is  neutralized  by  the  protective  materials 
formed  here  (anti toxines),  so  that  finally  it  can  no  longer  be  demonstrated 
here  in  animals  that  have  died  of  tetanus,  while  in  the  other  organs  large 
quantities  of  poison  can  be  found.  The  tetanus  poison  acts  like  strychnine 
in  causing  increased  excitability  of  the  spinal  cordi — i.  e..  the  motor  cells  in  the 
anterior  horns — but  in  order  to  produce  muscular  spasms  there  must  also  be  a 
sensory  stimulus.  The  excitability  of  the  sensor}^  nei'ves  has  been  found  by 
some  to  be  markedly  increased,  while  that  of  the  motor  nerves  remains  un- 
changed. The  slightest  peripheral  stimulus  becomes  augmented  in  the  sen- 
sory tracts  so  that  it  causes  a  contracture.  The  action  of  the  poison  is  ac- 
cordingly partly  a  peripheral  and  partly  a  central  one  (Brunner).  Somani 
fed  herbivora  and  carnivora  with  pure  cultures  of  tetanus  bacilli  and  the 
meat  from  animals  that  had  died  of  tetanus,  and  found  that  all  the  animals 
remained  healthy.     The  faeces  of  the  animals,  particularly  the  herbivora, 


§73.]  TRAUMATIC   TETANUS.  365 

■contained  an  active  tetanus  poison  which,  as  already  known,  can  be  spread  by 
the  faeces  and  manure  of  horses,  for  example. 

Tetanus  Immunity  in  Animals.— Great  interest  attaches  to  the  experi- 
ments of  Behring  and  Kitasato  relating  to  the  production  in  animals  of  im- 
munity from  tetanus.  These  authors  succeeded  in  curing  infected  animals, 
and  in  so  treating  healthy  ones  that  they  were  never  afterwards  affected 
by  the  tetanus  bacillus.  The  blood  and  serum  of  rabbits  which  have  been 
rendered  immune  from  tetanus  possess  the  power  of  destroying  the  tetanus 
poison.  They  are  both  prophylactic  and  curative.  By  transfusion  of  blood 
or  serum  remarlcable  therapeutic  effects  can  be  obtained ;  that  is,  infected 
animals  can  be  cured,  and  healthy  ones — mice,  for  example — can  be  rendered 
permanently  immune.  The  artificially  acquired  immunity  is  transmitted 
from  the  animal  to  the  foetus  in  utero,  and  persists  in  the  young  for  some 
time  after  birth.  Tizzoni  and  Cattani  have  made  white  mice  immune  by  the 
serum  of  the  blood  taken  from  frogs  and  pigeons  which  are  unsusceptible  to 
tetanus ;  but  Kitasato,  experimenting  with  the  blood  of  chickens,  has  con- 
tested their  assertions.  Kitasato  has  rendered  rabbits  immune  from  tetanus 
by  injections  of  iodoform.  Tizzoni  and  Cattani  state  that  rabbits  from  which 
the  spleen  has  been  removed  cannot  be  made  immune.  Behring,  Frank, 
Tizzoni,  and  others  prepai-ed  a  serum  containing  the  antitoxine  from  animals 
made  artificially  immune  and  used  it  on  human  subjects.  This  serum  acts 
chiefly  wpon  the  toxines  of  the  tetanus  bacillus,  diminishing  their  poison- 
ous action.  The  antitetanic  serum  has  been  employed  in  a  large  number  of 
cases  of  tetanus,  but  it  is  not  yet  possible  to  give  a  final  opinion  regarding  its 
therapeutic  value.  Some  authorities,  including  Roux,  Vaillard,  and  Doyon 
doubt  the  possibility  of  curing  by  antitoxine  a  case  of  tetanus  that  has  once 
developed,  but  they  admit  that  the  outbreak  of  the  disease  can  be  prevented 
by  prophylactic  inoculation. 

Disinfection  of  Objects  Infected  with  the  Tetanus  Poison.— The  disinfec- 
tion of  all  objects  infected  with  the  tetanus  jDoison  is  best  carried  out  by  sub- 
jecting them  to  the  action  of  steam  at  a  temperature  of  100°  C.  to  130°  C.  (212° 
to  266°  F.),  or  by  boiling  them  in  a  one-per-cent.  aqueous  solution  of  soda. 
For  the  disinfection  of  hospital  wards,  rooms,  etc.,  Bombicci  recommends 
nascent  chlorine,  while  a  ten-per-cent.  solution  of  chloride  of  lime  can  be 
used  for  stone  walls,  or,  better,  a  mixture  of  ten  parts  of  chloride  of  lime, 
twentj^-five  parts  of  quicklime,  and  one  hundred  parts  of  water.  Fluid  coal 
tar  is  excellent  for  wooden  walls.  Tizzoni  and  Cattani  recommend  a  mix- 
ture of  one  per  cent,  bichloride  of  mercury,  five  per  cent,  carbolic  acid,  and 
Ave  tenths  per  cent,  hydrochloric  acid  for  disinfecting  the  hands  of  the 
surgeon. 

Tetany. — Tetany  is  a  condition  characterised  by  a  pectiliar  irritability  of 
the  anterior  horns  of  the  spinal  cord,  causing  tonic  contractions,  particularly 
of  the  hands  and  feet.  It  is  sometimes  acute,  sometimes  subacute,  sometimes 
chronic,  and  may  be  of  a  benign  nature  or  absolutely  fatal.  Numerous  in- 
vestigations have  increased  our  knowledge  of  the  clinical  forms,  but  the 
etiology  is  still  not  fully  known.  Pfeiffer  distinguishes  the  following  va- 
rieties :  1,  the  epidemic  or  endemic  ('Jaksch''s  acute  recurrent  form) ;  2, 
the  tetany  of  pregnant  and  nursing  women ;  3,  the  tetany  following  re- 
moval of  the  thyroid  gland ;   4,  the  tetany   from  poisoning   by   ergotine, 


366  INFLAMMATION  AND  INJURIES. 

chloroform,  etc.  (toxic  tetany)  ;  5,  the  tetany  after  infectious  diseases ;  6, 
the  tetany  resulting  from  g-astro-intestinal  aifectious ;  7,  the  tetany  in  con- 
stitutional diseases.  The  variety  which  is  of  chief  interest  to  the  surgeon  is 
that  following"  removal  of  the  thyroid  gland  (for  particulars  see  Regional 
Surgery — Goitre).  Whether  certain  micro-organisms  can  be  looked  upon  as 
the  cause  of  tetany,  particularly  the  epidemic  form,  is  still  a  question. 

The  Clinical  Course  of  Tetanus. — The  symptoms  of  tetanus  appear 
after  a  variable  period  of  iucubation.  According  to  Rose,  to  whom 
we  are  indel)ted  for  an  excellent  monograph  on  tetanus,  the  disease  ap- 
pears in  half  the  cases  in  the  second  week  after  the  injury,  in  one  third  of 
the  cases  in  the  first  week,  in  one  fifth  of  the  cases  in  tlie  third  to 
fourth  week,  etc.  The  first  symptom  is  usually  a  peculiar  stiffness  and 
spasmodic  contraction  of  the  muscles  in  the  vicinity  of  the  injury.  Two 
to  four  days  later  it  is  noticed  that  the  patient  cannot  open  the  mouth 
properly,  and  he  complains  of  pain  in  the  muscles  of  mastication. 
At  the  same  time  there  is  usuall}^  a  high  fever,  though  in  the  less 
acute  cases  the  fever  may  be  absent.  As  a  residt  of  the  cramp-like 
contraction  of  the  facial  muscles,  the  countenance  assumes  a  peculiar 
rigidity.  There  soon  follows  a  certain  amount  of  stiffness  of  the  neck, 
with  tetanic  spasms  lasting  a  few  or  several  minutes,  and  affecting  at 
one  time  the  trunk  and  at  another  the  extremities ;  they  are  very  pain- 
ful, and  are  excited  by  the  slightest  external  irritation — for  example, 
by  touching  the  patient,  by  a  draught  of  air,  a  noise,  etc.  Many  of 
the  muscles  become  firmly  and  permanently  contracted.  The  tetanic 
contractions  are  caused  by  the  action  of  the  tetanus  poison  both  upon 
the  central  nervous  system  and  the  peripheral  nerves.  This  is  prob- 
ably a  reflex  action  due  to  stimulation  of  the  sensory  nerves  (see 
page  306).  The  fever  in  tetanus  is  usually  high,  the  rise  in  tempera- 
ture not  infrequently  reaching  41°  to  42°  C.  (105.8°  to  107.6°  F.),  or 
even  43°  to  44°  C.  (109.4°  to  111.2°  F.),  while  after  death  there  is 
sometimes  a  further  rise  to  about  45°  C.  (113°  F.).  This  excessive 
increase  in  body  heat  is  essentially  the  result  of  muscular  contraction, 
as  was  also  proved  by  Leyden's  experiment,  in  which,  within  two 
hours,  the  temperature  of  a  dog  was  made  to  rise  from  39.6°  C. 
(103.2°  F.)  to  44.8°  C.  (112.6°  F.),  simply  from  the  frequently  repeated 
muscular  contraction  caused  by  powerful  electrical  stimulation  of 
the  spinal  cord.  The  patients  usually  retain  perfect  consciousness,  and 
are  bathed  in  sweat.  The  urine  contains  albumen,  probably  as  a  result 
of  the  tetanic  contraction  of  the  renal  arteries.  There  are  also  cases 
which  may  run  a  rapidly  fatal  course  and  yet  be  unaccompanied  by 
fever.  In  these  there  is  an  extensive  muscular  rigidity,  particularly 
about  tlie  head  and  trunk,  the  patients  hold  themselves  perfectly  stiff. 


§73.]  TRAUMATIC   TETANUS.  367 

and  there  are  none  of  the  above-described  muscular  contractions 
alternating  with  a  momentary  abatement  of  the  rigidity. 

Acute  tetanus  is  usually  fatal.  Death  may  occur  within  twenty- 
four  hours  from  the  beginning  of  the  disease,  or  after  the  lapse  of 
four  to  five  days.  There  is  also  a  subacute  or  chronic  form  of  trismus 
or  tetanus  which  ordinarily  is  not  accompanied  by  fever.  Sometimes 
the  tetanus  remains  limited  to  the  nmscles  in  the  neighbourhood  of  the 
injury,  affecting  perhaps  the  arm  alone,  or  the  injured  leg,  or  the  mus- 
cles of  the  head. 

Head  Tetanus. — Rose,  Bernhardt,  and  Giiterbock  state  that  the  so- 
called  head  tetanus  occurs  after  injuries  in  the  region  of  the  distribu- 
tion of  one  of  the  twelve  cranial  nerves.  It  is  distinguished  particu- 
larly by  tetanic  contractions  of  the  muscles  of  mastication — by  trismus, 
as  it  is  called — which  is  combined  with  facial  paralysis  and  spasm  of 
the  muscles  of  the  pharynx,  as  in  hydrophobia,  and  hence  is  some- 
times given  the  name  of  tetanus  hydrophobicus.  In  a  certain  number 
of  cases  spasms  alone  appear,  and  in  others  the  spasms  are  accom- 
panied by  paralytic  manifestations.  The  paralyses  occur  chiefly  in 
the  distribution  of  the  facial  nerve,  less  often  in  nerves  of  the  eye, 
while  the  motor  branches  of  the  fifth  remain  unparalysed,  and,  on  the 
contrary,  take  a  prominent  part  in  the  contractions  (Brunnei').  The 
rigidity  then  descends  to  the  neck,  trunk,  and  extremities.  The  con- 
tractions begin  on  the  same  side  as  the  injury  and  are  stronger  here. 
The  paralytic  manifestations  occur  regularly  on  the  same  side  as  the 
injury ;  and  in  case  the  injury  is  in  the  median  line  the  facial  paraly- 
sis may  be  present  on  both  sides.  The  paralysis  of  the  facial  nerve, 
according  to  Rose's  view,  is  caused  by  compression  of  the  swollen 
nerve  in  the  aqueductus  Fallopii,  but  this  cannot  always  be  dem- 
onstrated in  the  post-mortem  examination.  Head  tetanus  is  not  al- 
ways fatal,  particularly  chronic  cases,  which  Klemm's  statistics  show 
may  last  from  four  to  twelve  weeks,  and  are  much  more  apt  to  ter- 
minate favourably  than  the  acute  form  of  the  disease.  Giiterbock 
and  Bernhardt  collected  fourteen  cases  with  four  recoveries.  Klemm 
had  one  case  of  chronic  tetanus  hydrophobicus,  and  collected  the  re- 
ports of  twenty-four  others,  seven  of  which  recovered,  six  of  these 
being  chronic. 

Pathology  of  Tetanus. — The  anatomical  changes  in  tetanus  are  slight. 
The  microscopical  examination  of  the  spinal  cord  and  the  neighbouring  pe- 
ripheral nerves  shows  an  extensive  proliferation  of  the  cells.  Monastyrski 
found  half -moon-shaped  extravasations  of  blood  in  the  interstitial  connective 
tissue  of  the  spinal  cord  and  peripheral  nerves,  and  a  granular  infiltration  of 
the  nerve  cells. 


368  INFLAMMATION  AND  INJURIES. 

Prognosis  of  Tetanus. — Tlie  prognosis  of  tetanus  depends  chiefly  upon 
the  time  ol"  incubation  and  tlie  virulence  and  number  of  the  bacilli  or  spores 
(Beck).  The  acute  cases,  with  a  short  period  of  incubation,  usually  run  a 
fatal  course,  while  the  subacute  and  rare  chronic  cases  have  a  better  prog- 
nosis. Furthermore,  the  outcome  is  not  always  fatal  in  those  cases  where 
the  tetanus  is  confined  to  the  muscles  of  the  injured  limb  or  to  the  head 
(hydr<5phobic  tetanus).  The  earlier  tetanus  is  recognised  and  treated  jjroper- 
ly  the  better  the  prognosis.  According  to  Rose,  the  mortalitj'  of  tetanus  is 
88  per  cent. 

Treatment  of  Tetanus. — -Treatment  in  acute  tetanus,  if  it  is  fully 
developed,  is  of  little  eifeet.  The  treatment  is  local  and  constitutional. 
The  wound  should  be  treated  antiseptically,  and  if  possible  its  primary 
focus  should  be  destroyed.  Wounds  that  liave  been  soiled  by  dirt  or 
otlier  material  should  be  thoroughly  cleansed  and  disinfected.  As  the 
tetanus  bacillus  is  anaerobic,  the  wound  should  be  thoroughly  opened 
so  as  to  allow  free  access  of  the  air,  and  the  infected  tissues  should  be 
removed  with  the  knife,  scissors,  sharp  spoon,  or  thermo-cautery. 
Tizzoni  and  Cattani  recommend,  for  the  disinfection  of  wounds  in 
which  there  is  fear  of  the  development  of  tetanus,  a  oue-per-cent.  solu- 
tion of  nitrate  of  silver,  which  destroys  the  bacilli  and  the  spores  very 
rapidly  and  certainly — in  one  minute.  In  suitable  cases  early  ampu- 
tation of  the  injured  member  is  advisable.  Recoveiy  has  followed  in 
some  cases,  and  in  others  amputation  was  unsuccessful  in  saving  life. 
Especially  in  tetanus  following  injuries  of  the  extremities,  attempts 
have  been  made  to  arrest  the  disease  by  exposing  and  stretching  the 
principal  nerve  trunks — the  sciatic,  for  instance — which  supply  the 
injured  portion  of  the  body,  and  Yerneuil,  Kocher,  and  others  have 
reported  cures  by  this  treatment.  The  good  obtained  from  nerve- 
stretching  in  infectious  tetanus  is  certainly  open  to  doubt  (§  97). 
With  the  local  treatment  we  combine  injections  of  antitetanic  serum. 
A  number  of  cures  from  the  use  of  the  serum  have  already  been 
reported.  The  injections  are  useful  chiefly  in  the  incubation  period,  or 
before  the  disease  has  fully  devel(jped. 

The  remainder  of  the  treatment  for  tetanus  is  purely  symptomatic. 
Subcutaneous  injections  of  morphine  are  often  used,  accompanied  by 
the  administration  of  chloral  hydrate  (three  to  five  grammes  i^ro  die) 
by  the  rectum,  or  large  doses  of  chloral  hydi'ate  or  bromide  of 
potassium  may  l)e  given  internally,  two  grammes  of  chloral  hydrate 
being  alternated  with  the  same  amount  of  bromide  of  potassium  every 
two  hours.  Kane  states  that,  of  two  hundred  and  twenty-eight  cases 
treated  with  chloral  hydrate,  one  hundred  and  thirty-four  recovered 
and  ninety-four  died.  Of  ninety-three  treated  with  chloral  hydrate  in 
combination  with  other  remedies,  thirty-three  died.     The  most  efficient 


§  74.]  SEPTICEMIA.  369 

means  for  quieting  a  patient  during  a  paroxysm  is  to  administer  chloro- 
form by  inhalation ;  but  after  the  cessation  of  the  narcosis  the  mus- 
cular spasm  immediately  recurs.  Curare,  the  Indian  arrow  poison, 
which  has  the  power  of  paralysing  voluntary  muscles,  is  an  exceed- 
ingly valuable  remedy,  though  very  inconstant  in  its  efEects  on  account 
of  its  variable  chemical  composition.  The  success  of  the  curare  treat- 
ment has  not,  however,  been  very  encouraging.  Its  concentration 
varies  within  wide  limits.  Curare  can  be  injected  in  the  dose  of  about 
0.015  to  0.05  gramme  every  quarter  to  half  to  one  hour.  Karg  has 
curarised  patients  (by  subcutaneous  injection)  till  respiration  became 
paralysed,  after  previously  performing  a  prophylactic  tracheotomy  for 
facilitating  artificial  respiration ;  but  all  the  cases  treated  in  this  way 
terminated  fatally.  It  is  a  better  plan  to  combine  the  administration 
of  narcotics  with  injections  of  curare.  Inhalations  of  amyl  nitrite 
(five  drops  twice  a  day)  have  been  used  with  success.  Bacelli  has 
obtained  satisfactory  results  by  injections  of  carbolic  acid  (0.01 
gramme  every  hour).  Sormani  recommends  iodoform.  According 
to  the  latter's  experiments,  the  tetanus  poison  is  neutralised  by  iodo- 
form, or  by  the  iodine  derived  from  it ;  and  by  treating  the  wound 
with  iodoform  during  the  period  of  its  incubation  tetanus  can  be 
prevented.  He  states  that  mice  inoculated  simply  with  earth  died  of 
tetanus  in  less  than  three  days ;  but  if  the  earth  used  in  the  inocula- 
tions was  first  mixed  with  iodoform  the  animals  remained  unaffected 
by  the  disease.  Pure  cultures  are  not  changed  when  iodoform  is 
added  to  them,  but  are  killed  in  one  minute  by  the  addition  of  a 
one-per-cent.  solution  of  nitrate  of  silver  (Tizzoni,  Cattani).  Sormani 
also  recommends  iodol,  a  two-per-cent.  acid  solution  of  bichloride 
of  mercury,  and  chloral  with  camphor.  The  further  treatment  of 
the  disease  consists  in  careful  isolation  of  the  patient,  and  in  keeping 
away  from  him  every  sort  of  external  irritation  or  disturbance,  par- 
ticularly during  the  stage  when  the  muscular  spasms  are  a  prominent 
symptom. 

De  Eenzi  has  succeeded  in  curing  four  out  of  a  total  of  five  cases 
of  tetanus  by  securing  to  the  patient  absolute  rest,  which  is  the  very 
best  curative  agent  at  our  disposal.  De  Renzi  places  the  patient  with 
tetanus — the  ears  having  been  plugged — in  a  room  which  is  completely 
isolated,  absolutely  quiet,  and  darkened.  All  the  necessary  manipula- 
tions in  the  care  of  the  patient  are  performed,  as  far  as  possible,  in  the 
dark.  The  nourishment  is  entirely  fluid.  When  the  pain  is  severe 
De  Renzi  gives  belladonna  and  ergot  internally. 

§  Y4.  Septicsemia, — The  term  septiccemia  is  given  to  a  poisoning  of 
the  body  (intoxication)  which,  as  a  rule,  rapidly  terminates  in  death. 


370  INFLAMMATION   AND   INJURIES. 

and  is  not  characterised  by  the  formation  of  such  metastatic  suppura- 
tive processes  as  occur  in  the  disease  called  pyaemia  (pus  poisoning), 
which  is  closely  related  to  it.  Septicaemia  is  usually  found  in  conjunc- 
tion with  putrefactive  (gangrenous)  changes  in  a  wound  or  inflamma- 
tory focus,  though  it  may  sometimes  have  an  intestinal  or  pulmonary 
origin.  Occasionally  the  point  of  entrance  of  the  infection  cannot  be 
found  (cryptogenetic  septicaemia.)  It  is  often  perfectly  impossible  to 
make  a  sharp  distinction  between  pyaemia  and  sepsis,  as  the  two  dis- 
eases are  frequently  found  in  combination,  both  clinically  and  anatom- 
ically, and  hence  the  term  septicojnjcemia.  Examination  of  the  blood 
for  bacteria  is  of  great  importance  for  the  etiology  and  prognosis  of 
sepsis  and  pyaemia.  Absorption  of  the  toxines  alone  seldom  causes 
death ;  bacteria  can  usually  be  found  in  the  blood  of  the  fatal  cases. 

Etiology  of  Septicaemia  in  Man. — Virchow,  Billroth,  and  others  produced 
septica?mia  by  injecting  decomijosing  substances  into  the  vascular  system 
and  tissues  of  animals,  and  the  discoveries  in  fermentation  and  decomposi- 
tion which  were  made  about  the  same  time  helped  to  shed  light  upon  the 
importance  of  lower  organisms  in  the  production  of  sepsis.  Then  Panum 
demonstrated  that  analogous  septic  diseases  could  be  excited  by  using  de- 
composing fluids  which  had  been  boiled  after  the  fungi  existing  in  them 
were  removed.  This  theory  of  the  origin  of  septica?mia,  partly  from  bacteria 
and  partly  from  fluids  free  of  bacteria,  is  now  being  still  further  elaborated, 
so  that  at  present  we  distinguish  two  principal  forms  of  septica?mia,  one 
caused  by  fungi  and  the  other  by  soluble  chemical  poisons.  The  septicaemia 
due  to  the  presence  of  bacteria  is  an  infectious  disease  capable  of  transmis- 
sion to  other  animals ;  in  other  words,  the  blood  of  animals  having  this  kind 
of  sepsis  will  produce  the  same  disease  when  inoculated  into  healthy  animals. 
The  virulence  of  the  blood  increases  each  time  it  is  taken  from  an  animal 
having  the  disease  and  inoculated  into  a  healthy  one. 

In  the  second  form  of  septicaemia  the  blood  contains  dissolved  in  it 
chemical  poisons  or  gases,  the  poisonous  products  of  the  metabolism  of  the 
fungi,  and  it  is  not  infectious  any  more  than  the  blood  of  an  individual  suf- 
fering from  strychnine  or  prussic-acid  jioisoning. 

Between  the  two  forms  of  septicaemia  the  one  due  to  toxines  and  the 
other  to  bacteria,  there  are  numerous  ti-ansition  and  combined  forms :  in 
other  words,  bacteria  of  every  description  are  sometimes  found  in  the  blood 
of  those  suffering  from  poisoning  by  the  chemical  products  of  bacterial 
metabolism. 

The  changes  which  take  place  in  decomposition  are  of  great  importance 
for  an  understanding  of  the  etiology  of  septicaemia.  It  has  been  mentioned 
that  in  the  decomposition  excited  in  albuminous  bodies  by  bacteria,  various 
substances  are  foi'med,  the  chief  of  which  are  peptones  and  similar  bodies, 
nitrogenous  bases  (leucine,  tyrosine,  amine),  organic  fatty  acids,  aromatic 
products,  colouring  matters,  and  particularly  poisonous  toxalbumens,  and 
certain  alkaloids  to  which  have  been  given  the  name  of  cadaver  alkaloids  or 
ptomaines.     The  latter  possess  intensely  poisonous  properties.     It  had  long 


§74]  SEPTICAEMIA.  37I 

been  known  that  toxic  bodies  were  present  in  the  products  of  decomposition, 
as  Panum,  in  1863,  had  isolated  from  putrefying  substances  his  putrid  poison. 
Bergmann  and  Schmiedeberg  obtained  a  crystalline  body,  sepsine,  Billroth 
discovered  another,  etc.  Selmi  was  the  first  to  recognise  the  nature  of  these 
bodies,  and  he  gave  them  the  name  of  cadaver  alkaloids  or  ptomaines. 
Brieger  and  others  have  obtained  several  ptomaines  in  a  pure  state,  such  as 
collidine,  peptoxine,  neurine,  neuridine,  choline,  etc.,  and  have  investigated 
their  action  upon  animals.  Paterno,  Spica,  and  others  found  that  ptomaines 
are  also  a  product  of  normal  metabolism,  though,  of  course,  they  are  formed 
in  small  amounts.  They  are  hence  not  exclusively  decomposition-products 
of  the  albuminoid  bodies  in  the  presence  of  bacteria.  The  poisonous  ptomaines 
are  called  toxines.  Bergmann  and  Angerer  have  proved  that  febrile  dis- 
eases similar  to  septicaemia  can  be  produced  by  non-bacterial  poisons  such  as 
ferments.  In  a  case  of  septic  (putrefactive)  intoxication  occurring  without 
the  presence  of  micro-organisms  in  the  blood,  there  will  somewhere  be  found 
a  focus  of  suppuration  or  some  decomposing  pus  or  blood,  the  decomposition 
being  due  to  micro-organisms,  particularly  the  various  kinds  of  bacilli.  If 
the  focus  of  suppui-ation  is  removed  early  enough  recovery  may  take  place. 
In  these  foci  of  suppuration  or  gangrene  there  will  be  not  only  the  bacteria 
of  decomposition,  but  many  others,  such  as  pyogenic  staphylococci,  strepto- 
cocci, and  different  bacilli. 

Septicemia  in  man  is  caused  sometimes  by  bacilli  and  sometimes  by  cocci 
(Streptococcus  pyogenes,  Streptococcus  septicus  Fliigge,  Staphylococcus 
aureus).  In  the  septicaemia  due  to  progressive  gangrenous  emphysema  vari- 
ous bacilli  have  been  demonstrated.  Chameon,  Rosenbach,  and  others  found 
the  same  bacilli  which  Koch  proved  to  be  the  cause  of  malignant  oedema — 
a  disease  running  a  rapidly  fatal  course  in  mice,  guinea-pigs,  and  rabbits. 

These  oedema  bacilli  (Figs.  304,  305),  which  Pasteur  formerly  designated 
as  vibrions  septiques,  were  described  on  pages  339  and  340.  It  is  interesting 
to  note  that  the  symptomatic  anthrax  occurring  endemically  in  cattle  is  pi-o- 
duced  by  similar  bacilli,  and  that  their  multiplication  in  the  subcutaneous 
cellular  tissue  causes  inflammatory  swelling  with  the  evolution  of  gas.  Fur- 
thermore, in  hsemorrhagic  sej)tica3mia  many  kinds  of  bacilli  have  been 
found.  Lubarsch  observed  a  case  of  septic  pneumonia  in  a  newborn 
child  which  died  two  days  after  birth.  He  cultivated  from  the  lungs  and 
spleen  rod-shaped  organisms  which  in  the  main  corresponded  with  Gartner's 
Bacillus  enteritidis.  Sepsis  results  in  some  cases  from  endocarditis  with 
old  or  recent  vegetations  upon  which  streptococci  are  deposited  from  the 
blood,  giving  rise  to  infected  emboli. 

Experimental  Septicaemia  in  Animals. — Thanks  to  Robert  Koch,  we  pos- 
sess a  more  accurate  knowledge  of  human  septicaemia  on  account  of  this  in- 
vestigator's experiments  upon  animals.  There  is  a  toxic  septiccemia  (septic 
intoxication),  and  a  septicaemia  w^hich  is  bacterial  in  its  nature  (transmissi- 
ble septic  infection).  Toxic  septicaemia  occurs  after  the  injection  of  large 
amounts  of  decomposing  substances  into  the  subcutaneous  cellular  tissues- 
Immediately,  or  soon  after  the  injection,  there  ensue  restlessness,  weakness, 
cramps,  often  vomiting.  Anally  paralysis,  and  not  infrequently  death  follows 
in  a  few  hours  from  paralysis  of  respiration.  No  bacteria  are  found  in  the  blood 
or  internal  organs.    If  decomposing  fluids,  with  the  bacteria  of  decomposition. 


3Y2 


INFLAMMATION   AND   INJURIES. 


are  kept  for  twenty-four  hours  in  the  incubator  at  a  tempei'ature  of  40°  to 
41°  C.  (104°  to  105.8°  F.)  and  then  used  for  injection,  the  poisonous  effects  are 


Fig.  311. — Bacilli  of  septicaemia  in  a  vein  of  the  diaphragm,  taken  from  a  septicfemic  movise. 
White  blood-corpuscles,  some  containing  bacilli,  and  some  changed  into  masses  of  bacilli. 
X  700  (Koch). 


very  pronounced  ;  but  if  the  fluid  is  treated  in  the  same  way  for  forty-eight 
hours,  no  effects  follow  its  injection. 

In  the  bacterial  septicsemic  infection  great  numbers  of  bacteria  will  be 
found  in  both  the  blood  and  the  tissues.  Koch  showed  that  there  were  two 
kinds  of  bacterial  septicaemia :  the  septicaemia  of  mice  and  the  septicaemia  of 
rabbits,  both  of  which  are  caused  by  bacilli.  The  bacilli  of  mouse  septicae- 
mia are  very  fine  rods  (Figs.  311,  313),  like  the  bacilli  of  swine  erysipelas ; 
while  the  bacilli  of  rabbit  septicaemia,  recently  described  by  Gaffky,  are 
identical  with  or  closely  related  to  the  bacteria  of  chicken  cholera,  the  bacilli 
of  swine  fever,  and  the  bacilli  of  duck  cholera.  Hueppe  proposes  to  call 
these  micro-organisms  the  bacteria  of  septicaemia  haemorrhagica.  There  are, 
of  coui'se,  poisonous  metabolic  x^roducts  develoj)ed  in  these  bacterial  septicae- 
miae,  and  Hoffa  has  isolated  from  the  animals  suffering 

from  rabbit  septicsemia  a  poisonous 

base,     methylguanidin     (CsHvNs), 

probably   produced  by  the  oxida- 
tion of  creatin.     Animals  are  also 

afflicted  with  cocci-septicaemiae.   To 

this  class  belongs  FrankeFs  coccus 

of  sputum  septicaemia,  which,  when 

the  saliva  from  the  human  mouth 

is  injected  into  rabbits,  is  the  ex- 
citing cause   in  these   animals  of 

septicaemia.     This  same  coccus  is 

in  all  probability  the  excitant  of 

croupous  pneumonia  in  man.    The 

Streptococcus  septicus  and  a  coc- 
cus found  by  Nicolaier  in  foul  earth  are  precisely  similar  to  the  Streptococcus 
pyogenes^  as  is  also  the  Micrococcus  tetragonus.    Severe  septicaemia  is  occa- 


FiG.  312.— Blood  from 
a  septicsemic  mouse, 
dried  on  a  cover  glass, 
stained  with  methyl 
violet,  and  laid  in 
Canada  balsam.  Eed 
blood-corpuscles  and 
small  bacilli,  x  700 
(Koch). 


Fig.  313.— White  blood- 
corpuscles  from  a  vem 
in  the  diaphragm  of 
a  septicffiinic  mouse. 
This  shows  how  the 
corpuscles  become 
gradually  changed  in- 
to a  mass  of  bacilli. 
X  700  CKoch). 


§  74.]  SEPTICEMIA.  373 

sionally  transmitted  frora  parrots  to  man.     Lepetit  found  as  its  cause  a  small 

coccus  which  he  obtained  from  the  blood  and  made  pure  cultures  of.     He 

found  the  Stajjhylococcus  aureus  and  citreus  in  the  lungs. 

Bacteria  of  Decomposition. — Hauser  has  taught  us  the  morphology  and 

biology  of  three  kinds  of  bacteria  causing  decomposition,  and  called  by  him 

Proteus  vulgaris,  Proteus  inirahilis,  and  Proteus  Zen- 

Jceri.     From  small  rods  similar  to  Cohn's  Bacterium  ».    ^ 

termo  there  develop  in  proper  nutritive  media  longer  «>   z?ey^  0 

rods  and  screw-shaped  filaments,  which,  after  exhaust-  ^     ^~^  §  /0 

ing  the  nutritive  medium,  change  into  short  rods  and  ®  **   ^     9 

spherules,   which  are  probably   spores.     These  three  ^    ^^ 

kinds   of    bacteria,   isolated    from    decomposing   sub-    Fig.  su.— Bacterium  sep- 

stances,  are  capable  of  exciting  decomposition,  while        ticcem%a,hmmorrhagicm 

'■  ^  ^  (Hueppe),   bacteria  of 

the  filtrate  freed  from  bacteria  did  not  have  this  power        chicken  cholera,  rabbit 

(saprogenic).      The  investigations  about   their   patho-        septictemia,  etc.    Dia- 
^•^.     '=^.  .*=  .  .  ,^        _  gramniatic    and    much 

genie  properties  and  their  relationship  to  septicaemia        enlarged. 

revealed  the  fact  that  these  three  bacteria  evolved,  by 

exciting  decomposition  of  animal  tissue,  a  violent  chemical  poison,  which, 
when  introduced  in  very  small  amounts  into  the  blood  and  lymphatic  vessels 
of  small  animals,  caused  the  death  of  the  latter  with  every  symptom  of 
putrid  intoxication.  These  bacteria,  which  are  saprophytic,  are  not  them- 
selves pathogenic — that  is,  they  are  not  capable  of  developing  within  the 
living  body.  According  to  Brunner,  however,  the  Proteus  vulgaris  is  fre- 
quently of  importance  in  the  most  acute  cases  of  puerperal  sepsis ;  it  is  pos- 
sible that,  like  the  Bacillus  coli  communis,  it  passes 
from  the  rectum  into  the  female  genital  tract.  Ac- 
cording to  E.  Levy,  the  Proteus  vulgaris  (Hauser)  is 
to  be  looked  upon  as  a  germ  of  decomposition  which 
has  a  variable  poisonous  action,  and  when  injected 
subcutaneously  into  dogs,  mice,  and  rabbits  it  causes 
the  typical  picture  of  sepsis,  and  particularly  an 
acute  hsemori'hagic  gastro-enteritis.  A  number  of 
the  cases  of  meat  poisoning  are  caused  by  this  bacil- 
lus proteus  (Hauser). 

Ferment  Intoxication  and  Septicaemia.— Semmer, 
Rossbach,  and  Rosenberger  have  made  experiments 
which  show  that  after  the  injection  of  ferments  or  sterilised  septic  blood  the 
animals  thus  treated  will  die  of  sepsis,  from  the  development  of  bacteria  in 
the  blood.  If  these  experiments  are  free  from  error,  it  seems  to  prove  that 
the  properties  of  the  blood  are  so  changed  by  the  injection  of  the  above- 
named  substances  that  it  is  rendered  possible  for  bacteria  to  develop  in  it — a 
thing  which  would  be  impossible  if  normal  conditions  existed  in  the  blood 
and  tissues.  But  there  is  some  reason  to  doubt  that  the  substances  injected 
in  these  experiments  were  actually  free  from  all  contamination  by  bacteria. 
Bergmann  and  Angerer  have  made  some  interesting  discoveries  as  to  the 
relationship  of  ferment  intoxication  to  septicaemia.  It  is  well  known  that 
Birk  and  others,  by  transfusing  blood  containing  ferment,  or  by  injecting 
fibrin  ferment  into  the  blood,  obtained  in  the  animals  experimented  upon, 
both  during  life  and  after  death,  the  same  jDhenomena  which  occur  after  the 


.' 

-J  „.  '<^  • 

.^'-»    0'°' 

QO 

s*    » 

0. 

«    -»•>' 

\     -.V 

»=•«.      .» 

«   -5*/ 

•»                » 

•  * 

*-» 

^t 

.,"'* 

Fig.  315.— Pure  culture  of 

the  bacterium  of  hsem- 

orrhagic 

septicaemia 

(Hueppe) 

.     X  1,000. 

374  INFLAMMATION   AND   INJURIES. 

introduction  of  fluids  wliicli  are  decomposing  or  rendei'cd  foul  by  bacterial 
vegetation.  The  changes  consist  essentially  in  a  more  or  less  extensive  dis- 
integration of  the  white  blood-corpuscles,  with  a  secondary  formation  of 
fibrin  in  the  capillaries,  the  large  pulmonary  vessels,  and  in  the  heart.  Berg- 
niann  and  Angerer  excited  the  same  changes  by  injecting  large  doses  of  ster- 
ilised, transparent,  aqueous  solutions  of  pepsin  and  pancreatin.  The  severe 
ferment  intoxications  run  a  rapidly  fatal  course,  presenting  the  picture  of 
intoxication  by  decomposing  substances.  The  pure  ferment  consequently 
acts  in  a  manner  similar  to  the  pathogenic  bactex'ia — that  is,  mainly  by  de- 
stroying the  white  blood-corpuscles.  These  investigators  were  unable  to 
conflrm  the  above-mentioned  statements  of  Roseuberger  and  Rossbach,  that 
bacteria  can  develop  as  a  result  of  the  i^resence  of  sterilised  ferment  solutions 
in  the  blood. 

Occurrence  of  Septicaemia. — Septicoemia  in  man,  since  the  antiseptic 
method  of  treating  wounds  has  come  into  general  use,  is  of  much  less 
frequent  occurrence  than  was  formerly  the  case.  Antisepsis,  carefully 
carried  out  in  every  operation  and  iu  the  subsequent  treatment  of 
ever}^  wound,  is  the  best  guarantee  against  the  occurrence  of  septi- 
caemia. If  septicaemia  should  make  its  appearance  after  an  operation 
uj^on  healthy  tissue,  it  is  a  proof  that  there  has  somewhere  been  a 
transgression  of  the  rules  of  asepsis.  The  septic  poison,  the  micro- 
organisms, may  gain  access  to  the  wound  in  many  different  ways — for 
instance,  at  the  time  the  iujury  was  received,  or  by  infected  instru- 
ments, unclean  fingers,  etc. 

Pathological  Changes  in  Septicaemia, — The  pathological  changes  in 
septicaemia  consist,  in  the  first  place,  in  the  local  changes  at  the  point 
of  infection  and  the  surrounding  parts,  which  will  be  more  minutely 
described  when  we  come  to  the  symptomatology.  The  most  constant 
change  is  found  iu  the  blood  after  death.  It  is  dark-coloured,  like  tar, 
prone  to  rapid  decomposition,  and  not  infrequently  has  an  acid  reac- 
tion (carbonate  of  ammonia).  According  to  Grawitz  the  blood  is 
noticeably  thin ;  if  the  percentage  of  solids  in  the  blood  was  lowered 
from  21  per  cent  to  15  per  cent,  or  less,  death  always  occurred.  The 
above-mentioned  micro-organisms  will  be  found  in  the  vessels  and 
blood,  and  in  the  tissues  of  the  different  organs,  though  in  cases  of 
pure  intoxication  the  micro-organisms  will  not  have  a  general  distribu- 
tion throughout  the  body,  but  will  be  present  only  in  the  focus  of 
infection.  The  disintegration  of  the  white  and,  to  a  less  extent,  of 
the  red  blood-corpuscles,  brought  about  by  the  micro-organisms  or  by 
the  products  of  their  metabolism,  is  characteristic.  The  bacteria  are 
present  in  the  white  blood-corpuscles,  in  which  they  are  scattered 
through  the  system,  and  finally  change  the  leucocytes  into  masses  of 
bacteria  (Figs.  311,  313j.     As  a  result  of  the  disintegration  of  the 


§  74.]  SEPTICEMIA.  375 

white  blood-corj^uscles,  the  blood  possesses  an  increased  power  of 
coagulation.  In  consequence  of  the  changes  in  the  composition  of  the 
blood  and  the  alterations  in  the  walls  of  the  vessels,  allowing  their 
contents  to  escape  through  them,  there  arises  a  tendency  to  small  and 
large  haemorrhages  in  the  gastro-intestinal  tract,  in  the  mesentery  and 
omentum,  in  the  spleen,  endocardium,  pleura,  kidneys,  bladder,  and, 
in  short,  in  all  the  different  organs.  The  changes  occurring  in  the 
heart  and  lungs  are  not  constant,  there  being  sometimes  a  general 
pleurisy  and  sometimes  symptoms  of  pericarditis.  In  the  intestinal 
canal  there  is  frequently  an  extensive  enteritis,  taking  the  form  of  a 
catarrhal  swelling  with  ecchymoses,  and  the  formation  of  ulcers,  as  in 
a  dysenteric  inflammation.  The  spleen  is  almost  always  large  and 
soft,  and  the  liver  is  likewise  somewhat  enlarged,  congested,  and 
friable.  The  kidneys  are  increased  in  size,  the  parenchyma  is  in  the 
stage  of  cloudy  swelling,  and  there  is  a  catarrhal  change  in  the  uri- 
niferous  tubules.  The  above-mentioned  micro-organisms  will  be  found 
most  abundantly  in  the  kidneys,  and  chiefly  in  the  capillaries  of  the 
glomeruli  and  in  the  afferent  vessels.  The  changes  in  the  intei^nal 
organs  are  sometimes  very  slight.  Diffuse  metastatic  inflammations, 
embolic  infarcts,  and  foul  abscesses  also  occur  in  septicaemia,  especially 
when  the  latter  is  combined  with  pysemia  (pyo-sej)tic£emia) ;  but  they 
are  by  no  means  so  frequent  or  so  characteristic  of  septicasmia  as  are 
the  metastatic  suppurations  for  pysemia. 

The  Clinical  Course  of  Septicaemia. — The  symjjtoms  of  septicsemia 
are,  for  the  most  part,  characterised  by  the  presence  of  a  high  and 
generally  continuous  fever,  and  by  a  number  of  inflammatory  pro- 
cesses. The  two  different  forms  of  septicaemia — distinguished  in 
respect  to  their  etiology,  the  putrid  or  septic  intoxication  due  to  the 
products  of  bacterial  metabolism,  and  that  due  to  the  presence  of  bac- 
teria— cannot  clinically  be  sharply  differentiated,  and  in  man,  as  we 
have  stated  before,  they  not  infrequently  occur  in  combination.  It  is 
impossible  to  describe  the  symptoms  of  septicaemia  so  as  to  include  all 
its  forms. 

The  wounds  which  are  capable  of  giving  rise  to  septicaemia  may  be 
fresh  or  granulating.  Every  wound,  no  matter  how  small,  can  be  the 
starting-point  for  septic  infection.  The  mode  of  development  of  the 
wound  infections  was  described  at  length  in  §  QQ.  The  local  manifes- 
tations at  the  point  of  the  injury  vary  greatly,  and  they  may,  in  fact, 
be  entirely  absent,  as  in  the  cases  of  septicaemia,  which  run  a  very 
acute  course.  These  are  characterised  by  a  rapid  febrile  intoxication 
of  the  whole  system,  which  occurs  before  there  are  any  local  symp- 
toms in  the  wound.     In  the  worst  cases  there  is  a  gradual  clouding 


376 


INFLAMMATION   AND   INJURIES. 


of  the  mind,  followed  bj  stupor  and  death  within  the  first  two  or 
three  days. 

The  febrile  movement  is  not  characteristic  in  septicemia  ;  in  fact, 
there  are  forms  of  the  disease  which  run  their  course  without  any  fever 
at  all.  On  the  other  hand,  the  frequency  of  the  pulse  is  always  notice- 
ably increased  (Fig.  316).  If  the  ordinary  wound-fever,  occurring 
after  open  injuries  from  the  absorption  of  the  products  of  decomposi- 
tion, is  looked  upon  as  a  septic  intoxication,  it  must  be  admitted  that 
we  frequently  meet  with  transient  abortive  forms  of  septic  intoxica- 
tion, which  are  marked  by  a  moderate  rise  of  temperature  to  about  39° 
C.  (102.2°  F.),  and  terminate  favourably  in  a  few  days  without  giving 


Puis 

Tage:      1     i     2     |     3 

1 

5 

6         7          8 

9 

10 

-! 

180 

170 

160 

ISO 

140 

130 

120 

110 

100 

90 

80 

,..    .  .  70 

re 

f    u 

fu 

f^c 

r  u 

r\a 

r  a 

/■'  a 

/' 

a 

f 

a 

f 

a\ 

11,5 

41,0 

40,5 

^40,0 

39,5 

39.0 

38,5 
38,0 
37,5 
37,0 
36,5 

j 
1 

f 

1 — 1 

/■••■ 

/ 

/\ 

\ 

/^ 

J 

7 

/ 

V 

/ 

y  *'• 

A 

1 

j] 

A 

1 ' 

'  1 

\\ 

\A 

1  ■ 

iA 

V 

V 

\ 

Jj  ^ 

/ 

'/ 

\ 

/• 

t 

_1 

_ 

_ 

1 

_ 

2 

__ 

_^ 

^ 

Fig.  316 


Temperature  cur%-es  in  septicaemia :  1,  temperature  curve  in  septicemia,  with  high 
fever:  death  with  a  temperature  of  il^  C.  (105.6  F.),  and  pulse  of  170  on  the  third  day  after 
the  operation  (laparotomy ) ;  2,  temperature  curve  in  septicemia  with  a  slight  rise  ot  tem- 
perature; death  on  the  fourth  day  after  the  injury  (gun-shot  wound),  preceded  by  a  sub- 
normal temperature  and  very  rapid  pulse. 


rise  to  any  appreciable  complication  in  the  wound  or  in  the  internal 
organs.  This  simple  septic  fever  is  of  very  common  occurrence,  while 
it  is  relatively  seldom  that  we  meet  with  the  above-mentioned  severe 
cases  of  septic  intoxication  which  run  a  rapidly  fatal  course.  In  dis- 
cussino-  fever  in  general,  we  learned  that  the  latter  may  be  caused  by 
the  absorption  of  substances  which  were  not  decomposed,  such  as  fibrin 
ferment,  etc. — a  condition  which  \^olkmann  and  Genzmer  have  desig- 
nated as  wound-fever.  Consequently  our  present  knowledge  of  the 
etiology  of  fever  makes  it  impermissible  to  look  upon  every  rise  in 
temperature  in  those  who  have  been  injured  as  a  septic  fever. 

All  cases  of  general  sepsis  in  which  the  inflammation  is  plainly 
spreading  from  the  point  of  infection  have,  in  general,  an  unfavourable 
prognosis.     The  severity  of  the  constitutional  symptoms  and  the  ex- 


§  74.]  SEPTICEMIA.  377 

tent  of  the  local  inflammatorj  process  vary  here,  too,  very  much,  the 
latter  showing  all  the  steps  from  a  mild  lymphangitis  to  a  violent  sep- 
tic phlegmon  or  an  acute  septic  gangrene.  In  this  class  belong  the 
<3ases  of  septic  infection  which  arise  from  very  slight  injuries,  such  as 
are  not  uncommon  on  the  fingers  of  surgeons  after  operations  upon  ab- 
scesses, decomposing  tissue,  etc.,  from  infection  by  putrefying  matter. 
After  twelve  to  twenty -four  hours  there  is  a  chill,  and  the  temperature 
rapidly  rises  to  39.5°  C.  (103.1°  F.)  or  40°  C.  (104°  F.)  and  higher,  the 
small  wound  on  the  finger  becomes  painful  and  is  inflamed,  the  epitroch- 
lear  and  axillary  glands  swell,  and  red  streaks  appear  on  the  arm  (septic 
lymphangitis).  By  the  next  day,  if  proper  treatment  is  employed,  the 
.septic  infection  may  have  run  its  course,  or  recovery  may  take  place 
with  the  formation  of  pus  at  the  point  where  the  injury  was  received, 
and  with  the  development  of  circumscribed  abscesses  in  the  epitrochlear 
and  axillary  glands,  or  death  may  follow  from  general  seiDtic  poisoning. 
In  other  instances,  the  septic  inflammation  starting  from  the  wound  is 
.severe,  and  leads  to  an  extensive,  rapidly  spreading  cellulitis,  which  is 
accompanied  by  high  fever,  as  described  on  page  338.  Rarely,  and 
then  particularly  after  severe  traumatisms,  such  as  a  "  run-over  "  acci- 
dent, a  rapidly  advancing,  putrefactive  inflammation  will  develop  with 
the  evolution  of  gas  in  the  tissues,  usually  terminating  in  death  within 
the  first  forty-eight  hours.  The  gangrene  of  the  tissues  in  such  cases 
may  in  the  first  place  be  caused  by  the  injury  alone,  and  then,  in  addi- 
tion to  the  local  traumatic  gangrene,  there  is  added  a  rapidly  extend- 
ing decomposition,  due  to  the  entrance  of  the  germs  of  decomposition, 
which  may  spread,  and  involve  the  entire  extremity.  Sometimes  this 
traumatic  origin  of  the  gangrene  due  to  contusion  of  the  tissues  can  be 
■excluded,  and  yet  there  will  be  a  rapidly  spreading  gangrene,  with  de- 
composition and  the  evolution  of  gas.  This  is  sometimes  the  case  in 
snake  bites.  The  acute  purulent  oedema  of  Pirogoff  and  the  gangrene 
foudroyante  of  Maisonneuve  belong  to  those  worst  forms  of  septic  in- 
flammation. The  affected  extremity  is  usually  excessively  swollen, 
partly  from  oedema  and  partly  from  the  gases  produced  by  decomposi- 
tion. At  the  same  time  there  is  given  ofl:  a  foul  odour,  and  a  crackling 
emphysema  of  the  skin  radiates  in  all  directions  from  the  wound.  The 
muscles  become  changed  into  a  reddish-brown  mass  full  of  bubbles  of 
^as.  Coma  and  death  follow  in  a  few  days,  usually  preceded  by  an  in- 
crease in  the  oedema.  This  progressive  gangrenous  emphysema  {gan- 
grene gazeuse) — which,  by  the  way,  is  of  very  infrequent  occurrence 
since  the  introduction  of  antiseptic  methods — is  caused  by  bacilli  similar 
to  those  which  Koch  identified  as  the  cause  of  malignant  oedema  in 
mice,  guinea-pigs,  and  rabbits.  Progressive  gangrenous  emphysema 
26 


378  INFLAMMATION   AND   INJURIES. 

occurs  in  conjunction  with  compound  fractures,  or  any  deep  wound 
into  which  eartli  or  some  other  material  containing  tlie  cederaa  bacilli 
has  penetrated. 

The  other  symptoms  of  septicaemia  referable  to  the  internal  organs 
are  caused  by  the  general  septic  infection.  Usually  the  spleen  is 
plainly  enlarged,  and  very  often  the  liver  also.  Kot  infrecpiently 
there  is  jaundice,  generally  of  a  h?ematogenous  nature,  as  a  result  of 
the  disintegration  of  the  red  blood -corpuscles  caused  by  the  micro- 
organisms or  their  products.  There  are  usually  gastro-intestinal  dis- 
turbances, which  in  the  severer  forms  of  septicaemia  give  rise  to  a. 
diarrhoea  which  is  sometimes  feculent,  sometimes  mucous,  or  even 
bloody -diphtheritic  in  character. 

The  urine  ordinarily  contains  albumen.  The  diffuse  inflammations 
of  the  pleura,  the  pericardium  and  endocardium  give  rise  to  marked 
symptoms  only  in  exceptional  cases.  There  are  not  infrequently  ex- 
anthematous  eruptions  of  the  skin,  which  take  the  form  of  blebs  or  pus- 
tules, or  resemble  urticaria,  measles,  or  scarlet  fever.  These  eruptions 
are  caused  in  part  by  the  bacteria  (bacterial  metastases  in  the  skin)  and 
in  other  cases  they  are  to  be  explained  as  angioneuroses  due  to  the  action 
of  bacterial  toxines  (Meyer).  Haemorrhages  in  the  skin  and  the  in- 
ternal organs  are  sometimes  a  prominent  symptom  (hsemorrhagic  septi- 
caemia, see  also  page  375).  Yeins  and  arteries  may  be  opened  by  ab- 
scesses, leading  to  dangerous  hsemorrhages. 

Prognosis  of  Septicaemia. — The  prognosis  of  septicfemia  is.  in  the  pro- 
nounced cases  of  bacterial  septicaemia,  for  the  most  i^art  unfavourable.  The 
cases  of  intoxication  by  decomposing  substances  in  which,  by  proper  treat- 
ment, we  can  remove  from  the  body  the  focus  of  infection,  have  relatively 
the  best  prognosis.  After  this  procedure  has  been  accomplished  the  absorp- 
tion of  the  products  of  bacterial  metabolism  ceases,  and  with  it  also  the 
poisoning.  But  it  is  important  to  bear  in  mind  that  a  patient  may  apparently 
recover  from  septicaemia  by  encapsulation  of  the  infectious  matter,  and  yet, 
after  the  lapse  of  a  longer  or  shoi-ter  time,  it  may  again  enter  the  circula- 
tion, being  set  free,  perhaps,  by  some  slight  trauma  or  by  a  violent  muscular 
contraction,  and  cause  the  death  of  the  patient.  The  experiments  of  Grawitz, 
Behring.  and  others  make  it  seem  probable  that  the  powers  of  the  organism 
for  withstanding  septic  intoxication  are  weakened  pinncipally  by  the  exten- 
sive disintegration  of  the  red  blood-corpuscles  brought  about  hj  the  toxic 
substances. 

Diagnosis  of  Septicsemia. — In  the  diagnosis  of  septicaemia,  the  behaviour 
of  the  original  wound  or  injury  and  the  inflammatory  manifestations  in  it, 
the  presence  of  decomposition  of  the  blood,  wound  secretion,  or  pus,  and  the 
presence  of  fever,  and  particularly  the  increased  frequency  of  the  pulse,  are 
all  important.  In  those  cases  of  septictemia  in  which,  without  noticeable 
local  inflammatory  symptoms,  there  occurs  within  a  few  houi'S  of  the  recep- 
tion of  the  injury  a  severe  fever,  the  diagnosis  can  usually  be  cleared  uj)  by 


§  74.]  SEPTICEMIA.  3Y9 

getting-  an  exact  history  of  the  injury.  A  small  and  very  rapid  pulse  is 
exceedingly  important  in  making  the  diagnosis  of  septicaemia.  The  greatest 
diagnostic  difficulties  will  be  met  with  in  those  cases  in  which  no  source  of 
infection  can  be  found,  in  the  so-called  cryptogenic  septicaemia  or  septico- 
pyaemia,  the  origin  of  which  can  only  be  ascertained  during  the  course  of  the 
disease  or  at  the  post-mortem  examination.  Wagner  has  published  a  very 
instructive  account  of  a  number  of  cases  of  this  kind. 

The  So-called  Surgical  Scarlatina.— In  speaking  of  the  symptomatology  of 
pyaemia  and  septicaemia,  we  mentioned  the  occasional  occurrence  of  exanthem- 
atous  eruptions  in  the  skin,  particularly  those  which  resemble  the  eruptions 
of  measles  and  scarlet  fever.  Surgical  scarlet  fever,  as  it  is  called,  has  been 
described  by  Thomas,  Riedinger,  and  Hoffa.  It  is  sometimes  a  purely  vaso- 
motor disturbance.  In  addition  to  this  eruption  of  septicaemia,  pyaemia,  and 
erysipelas,  due  to  vasomotor  disturbance,  there  is  also  a  real  scarlatina 
which  occurs,  particularly  in  children,  after  operations  and  the  reception  of 
wounds.  In  such  cases  the  poison  of  scarlet  fever  passes  directly  from  the 
wound  into  the  general  circulation.  E.  Koch  collected  twenty-six  cases  of 
true  scarlatina  following  operations  and  the  reception  of  wounds  among  the 
patients  of  the  children's  hospital  at  Basel,  and  he  states  that  the  period  of 
incubation  in  this  wound  scarlet  fever  is  shorter  than  in  the  usual  non- 
surgical form.  This  surgical  scarlatina  is  probably  due  mainly  to  strepto- 
coccus infection. 

Treatment  of  Septicaemia. — The  treatment  of  septicsemia  consists,  in 
the  first  place,  in  treating  any  injury  which  may  be  present  with  the 
greatest  surgical  care.  Every  infectious- wound  disease,  and  conse- 
quently septicsemia,  can  be  avoided  by  antisepsis  or  asepsis  if  strictly 
carried  out.  If  fever  follows  an  injury  or  an  operation,  the  wound 
should  be  most  carefully  examined,  and  any  retention  of  decompos- 
ing blood,  of  the  wound  secretion,  or  of  pus,  should  be  immediately 
remedied  by  incision  and  drainage,  and  this  should  be  followed  by  dis- 
infection with  a  1  to  1,000  solution  of  bichloride  of  mercury  or  a  three- 
to  five-per-cent.  solution  of  carbolic  acid.  The  special  treatment  for 
local  inflammation  and  suppuration  is  described  in  §§  67- Y2.  In  sep- 
ticaemia which  is  the  result  of  a  severe  septic  phlegmon  with  extensive 
gangrene,  it  may  not  infrequently  be  necessary  to  sacrifice  an  entire 
Kmb,  by  amputation  or  disarticulation,  to  save  the  life  of  the  patient. 
But  it  should  be  borne  in  mind  that  in  an  extensive  septic  cellulitis, 
numerous  free  incisions,  followed  by  thorough  disinfection  of  the  in- 
fective focus  thus  freely  exposed,  may  be  sufficient  to  answer  every 
purpose  ;  though,  on  the  other  hand,  amputation  should  not  be  too  long 
delayed,  as  the  patient  may  even  after  that  die  of  septicaemia.  The 
rest  of  the  treatment  is  wholly  symptomatic ;  there  is  no  effective 
remedy  for  counteracting  septic  constitutional  infection.  The  treat- 
ment of  the  fever  is  conducted  on  the  rules  laid  down  in  §  62.  If  the 
skin  of  an  infected  patient  is  dry,  Billroth  recommends  that  the  excre- 


380  INFLAMMATION  AND  INJURIES. 

tioii  of  the  poisonous  substances  be  hastened  by  exciting  pronounced 
diaphoresis,  either  by  pLicing  the  patient  in  a  warm  bath  for  an  hour, 
or  by  wrapping  him  up  in  warm  blankets,  or  by  administering  large 
quantities  of  a  hot  drink,  etc.  As  a  matter  of  fact,  we  know  from  the 
experiments  of  Brunner  and  others  that  the  bacteria  are  excreted  in  the 
sweat.  The  septic  diarrhoea  is  combated  with  opium,  tannin,  sub- 
nitrate  of  bismuth,  acetate  of  lead,  enemas  of  starch  paste  containing 
tannin,  opium,  etc.,  but  unfortunately  they  are  usually  without  much 
effect.  The  diet  of  the  patient  should  be  one  which  is  easily  assimi- 
lated, and  as  nutritious  as  possible.  Alcohol  in  the  form  of  strong 
wines  or  whiskey  should  be  given  freely.  Transfusion,  which  has  been 
used  by  Hueter  in  the  treatment  of  septicaemia,  is  not  to  be  recom- 
mended. 

§  75.  Pyaemia  (Pyohsemia)  or  Pus  Poisoning. — Pygemia  or  pyohferaia 
(from  TTvov,  pus,  and  alfxa,  blood)  was,  until  recently,  understood  to 
mean  an  infection  by  pus,  a  pus  poisoning,  caused  by  the  presence 
in  the  blood  of  the  elements  of  pus.  In  general,  jDygemia  is  charac- 
terised by  the  development  of  multiple  foci  of  suppuration  (metas- 
tases) in  the  different  organs,  as  a  result  of  the  wide  distribution  of 
the  pysemic  poison,  and  by  an  intermittent  type  of  fever.  It  has 
been  stated  before  (page  370)  that  it  is  often  impossible  to  draw  a 
sharp  distinction  between  pyaemia  and  septicaemia,  and  that  both  of 
these  diseases,  clinically  as  well  as  anatomically,  frequently  occur 
together  (septicopyaemia).  Consequently  it  is  becoming  more  and 
more  a  common  practice  to  make  no  attempt  at  distinguishing  be- 
tween septicaemia  and  pyaemia,  either  clinically  or  anatomically.  It 
would  be  simpler  to  include  both  diseases  under  one  name,  such  as 
pyosepticaemia  or  septicopyaemia. 

Etiology  of  Pyaemia— Micro-organisms. — Koch  has  produced  experimen- 
tally in  rabbits  a  pyaemia  which  is  similar  to  the  pyaemia  occurring  in  man. 
He  states  tliat  this  pyaemia  of  rabbits  is  excited  by  a  specific  coccus  which 
differs  from  all  other  cocci,  aud  in  particular  fr-om.  the  coccus  of  the  cheesy 
pus  found  in  rabbits. 

It  used  to  be  believed  that  the  pyemia  of  man  was  due  to  a  specific 
micro-organism,  but  this  theory  has  been  proved  to  be  incorrect ;  and,  in 
general,  there  are  found  in  pyaemia  the  same  micro-organisms  as  in  septi- 
caemia (see  pages  370-.374).  which  is  a  proof  that  the  two  diseases  cannot  be 
considered  etiologically  distinct.  The  common  pus  cocci  are  the  ones  most 
constantly  present  in  pyaemia  (see  pages  327-.330).  Any  acute  abscess  may 
give  rise  to  the  disease.  Under  ordinary  conditions  the  abscess  is  cut  off  by 
the  inflammatory  infiltration  surrounding  it  from  the  adjoining  healthy 
parts,  so  that  the  cocci  cannot  find  their  way  out  into  the  tissues  and  circu- 
latory fluids  of  the  body.  If,  however,  the  system  is  not  protected  in  this 
manner,  if  the  suppurating  area  is  subjected  to  a  certain  amount  of  pressure^ 


§  75.]  PYEMIA.  381 

or  if  there  is  any  considerable  new  addition  of  cocci  to  those  already  present, 
a  general  systemic  poisoning  from  the  cocci,  with  a  constitutional  febrile 
disease  and  the  formation  of  suppurating  foci  in  all  the  different  organs — in 
other  words  pyaemia — is  easily  produced.  Clinically  there  are  two  main 
groups  or  forms  of  the  pyaemic  process.  In  one  there  is  a  large  focus  of 
suppuration,  possibly  in  a  joint  or  following  a  compound  fracture,  and  start- 
ing from  this  focus  there  is  a  continuous  invasion  of  the  whole  body  by 
cocci,  accompanied  by  a  hectic  fever  and  followed  by  death.  In  the  second 
group  of  cases  there  is  no  large  focus  of  suppuration,  but  instead  there  is 
only  some  small  injury,  an  insignificant  cutaneous  abrasion,  or  a  punctured 
wound,  etc. ;  and  following  this  single  infection,  there  ensues,  without  any 
long-continued  suppuration  at  the  point  of  infection,  a  constitutional 
pyaemic  process  and  death,  though  the  primary  injury  may  have  cicatrised 
a  long  time  previously.  Any  collection  of  pus,  whether  in  the  lymph 
glands  or  in  any  of  the  organs,  can  suddenly  give  rise  to  fatal  pyaemia  if  the 
bacteria  enter  the  circulation  and  cause  metastases.  In  this  worst  form  of 
pyaemia  with  metastases  the  ordinary  pus  cocci  are  present.  Eosenbach 
found  that  the  most  frequent  cause  of  pyaemia  with  metastases  was  the  Strep- 
tococcus pyogenes  (see  page  329),  though  typical  examples  of  pyaemia  have 
been  known  to  follow  infection  by  other  cocci,  the  Staphylococcus  pyogenes 
aureus,  for  instance.  In  addition  to  the  pyaemia  due  to  cocci  there  is  also  a 
pyaemia  due  to  bacilli,  and  essentially  the  same  micro-organisms  are  present 
as  in  septicaemia,  and  hence  the  difficulty  of  distinguishing  the  two  diseases 
etiologically.  Chiari  discovered  a  capsule  bacillus  to  be  the  cause  of  pyaemia 
in  some  cases.  It  is  similar  to  Friedlander's  pneumonia  bacillus  and  Pfeif- 
fer's  Bacillus  capsulatiis.  For  the  pyaemia  caused  by  fungi,  see  page  373. 
The  course  of  pyaemia  in  man,  as  of  the  other  infectious-wound  diseases, 
varies  with  the  virulence  of  the  infecting  micro-organisms,  their  number^ 
the  susceptibility  of  the  individual  affected,  and  the  anatomical  location  and 
peculiarities  of  the  point  of  infection.  We  know  that  the  virulence  of  the 
same  micro-organism  is  subject  to  variation,  and  that  we  can  artificially 
weaken  tbis  virulence  of  the  septic  and  pya^mic  micro-organism ;  and  it 
has  been  proved,  by  the  experiments  of  Koch,  Gaffky,  and  others,  that  we 
can  increase  their  virulence  by  transmitting  the  micro-organisms  in  ques- 
tion from  one  animal  to  another  of  the  same  species — for  example,  from 
man  to  man. 

It  occasionally  happens  that  the  origin  of  a  pyaemia  is  not  clear  during 
the  life  of  the  patient,  as  is  true  of  septicaemia,  and  the  disease  is  then  called 
cryptogenic  pyaemia  or  pyosepticaemia.  In  such  cases  the  focus  of  the  infec- 
tion which  gave  rise  to  the  pyaemia  can  usually  be.  discovered  at  the  post- 
mortem examination. 

The  Pathological  Changes  Occurring  in  Pysemia. — The  severe  poisoning 
of  the  whole  organism  is  the  predominant  feature  of  septicaemia,  but  in 
pyaemia  the  local  inflammatory  processes  are  characteristic.  In  the  first 
place,  micro-organisms  will  be  found  in  the  vessels,  in  the  blood,  in  all  the 
various  organs,  and  in  the  metastatic  foci  of  suppuration  (Figs.  317,  318).  In 
the  blood  the  micro-organisms  are  present  in  the  plasma,  and  particularly  in 
the  white  corpuscles,  which  in  pyaemia  as  well  as  in  septicsemia  are  destroyed 
in  relatively  large  numbers.     The  bacterial  inflammation  of  the  walls  of  the 


382 


INFLAMMATION   AND  INJURIES. 


fe—    -^ 


-   a 


veins,  with  the  consequent  formation  of  thrombi,  whicli,  under  the  influence 
of  the  cocci  they  contain,  break  down  and  suppurate,  is  a  characteristic  fea- 
ture of  pytcmia  (see  §  69,  Phlebitis).  Portions  of  the 
infected  or  suppurating  thrombi  are  torn  olf  and  cai'- 
ried  away  by  the  blood  current  and  lodge  here  and 
there  as  emboli,  possibly  in  the  pulmonary  capillaries, 
and  wherever  they  find  lodgment  tliey  produce  throm- 
bosis and  suppuration  (metastatic  abscesses).  Collec- 
tions of  micrococci  and  metastatic  (embolic)  abscesses 
may  thus  be  found  in  the  muscles  of  the  heart,  the 
endo-  and  pericardium,  in  the  lungs,  pleura,  brain, 
liver,  spleen,  kidneys,  in  the  joints,  the  marrow  of  the 
bones,  the  muscles,  lymph  glands,  and,  in  short,  in 
all  the  different  organs.  Occasionally  a  reddening 
like  erysipelas  makes  its  appearance  in  the  skin,  but 
it  generally  disappears  after  the  lapse  of  a  few  days ; 
or  there  may  also  be  vesicles  or  pustules.  If  the 
pyaemia  runs  a  more  chronic  course,  the  pathological 
changes  are  less  pronounced ;  the  local  inflammatory 
processes,  the  metastatic  abscesses,  are  not  so  numer- 
ous, or  they  occur  in  the  stage  of  convalescence.  The 
marked  emaciation  of  the  patient,  the  fever  caused  by 
the  changes  in  the  organs  (see  §  62),  and  the  rem- 
nants of  the  earlier  local  inflammatory  or  suppura- 
tive processes,  are  characteristic  of  chronic  pya?mia. 

Occurrence  of  Pyaemia. — Since  the  advent  of  the 
antiseptic  period  of  surgery,  pysemia  has  occurred 
much  less  frequently  than  it  used  to.  Before  the  days 
of  antisepsis  many  hospitals  were  notorious  for  the 
pyaemia  and  infectious-wound  diseases  which  raged 
endemically  within  them,  but  now  in  these  same  hos- 
pitals the  antiseptic  method  of  treating  wounds  has  caused  the  infectious- 
wound  diseases  to  disappear  entirely.  The 
most  certain  way,  then,  of  preventing  pyae- 
mia is  to  observe  the  strictest  antisepsis  and 
asepsis. 

Clinical  Course  of  Pyaemia. — The  symp- 
toms of  pyaemia  are  characterised  by  the 
development  of  collections  of  micrococci 
and  multiple  metastatic  abscesses  in  differ- 
ent organs  of  the  body,  and  by  an  inter- 
mittent type  of  fever  with  intercurrent 
chills.  According  to  the  nature  of  the 
wound  the  cases  are  divided  into  two  main 
classes.  In  the  first  group  there  is  somewhere  a  collection  of  pus — for 
instance  in  a  joint — or  it  may  be  connected  with  a  compound  fracture, 
and  from  this  focus  the  whole  body  receives  constant  invasions  by 


Tig.  317. — Blood-vessel  in 
the  cortical  substance 
of  the  kidney,  taken 
from  a  pytemic  rabbit: 
a,  dense  mass  of  uiicro- 
cocci  on  the  inner  wall, 
containing  blood -cor- 
puscles ;  b,  b,  small 
groups  of  cocci  between 
the  blood  -  corpuscles. 
x700  (Koch). 


.^^- 


Fig.  318. — Specimen  from  the  liver 
of  a  man  who  died  of  pyfemia. 
The  capillaries  between  the  liver 
cells   are   filled  with  masses  of 


micrococci. 


75.] 


PYEMIA. 


383 


cocci,  and  at  the  same  time  there  is  an  intermittent  fever  with  inter- 
current chills.  In  the  second  gronp  of  cases  the  disease  originates  from 
the  single  infection  of  some  small  wound,  and  not  from  a  collection  of 
pus  which  has  been  in  existence  a  long  time.  In  this  second  group  the 
micro-organisms  multiply  in  the  system  and  spread  through  all  parts 
of  it,  and  wherever  they  find  lodgment  they  excite  inflammation  and 
suppuration.  Frequently  there  is  no  injury  present.  In  this  case  the 
pyaemia  has  developed  from  some  inflammatory  or  infectious  focus. 

The  pysemic  fever,  which  has  been  carefully  studied  by  Billroth 
and  Heubner,  does  not,  as  a  rule,  follow  a  regular  course,  but,  in  the 
main,  is  intermittent — that  is,  after  a  marked  elevation  of  temperature 


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r^ 

\ 

\ 

A 

V-^, 

J 

i 

\ 

/\ 

v 

\ 

M    N 

v| 

\ 

r 

\ 

s 

L_ 

1 

__ 

_ 





_ 

^^. 

Fig.  319. — Temperature  curve  of  pvEemia. 


there  is  a  sudden  fall  to  a  normal  or  subnormal  point,  and  the  tempera- 
ture remains  down  for  a  variable  length  of  time  (Fig.  319). 

Pyaemia  is  usually  ushered  in  by  a  rigour,  and  in  its  subsequent 
course  chills  are  of  more  or  less  frequent  occurrence,  the  temperature 
rising  with  greater  or  less  rapidity  after  each  chill  to  40°  C.  (104°  F.) 
or  higher,  and  just  as  rapidly  again  dropping  to  the  normal.  The 
length  of  time  that  each  chill  lasts  varies  very  much.  If  the  tempera- 
ture rises  gradually  there  will  be  no  chills. 

The  intermissions  may  be  repeated  every  twenty-four  hours  or 
every  other  day,  or  less  frequently.  After  several  days  have  elapsed 
without  any  fever  it  may  be  thought  that  the  pyemia  has  terminated 
favourably,  when  suddenly  there  will  be  a  fresh  chill  followed  by  high 
fever,  and  then  it  will  be  known  that  the  disease  is  still  active.  This 
peculiarly  irregular  course  of  the  pyaemic  fever  is  due  to  the  fact  that 
from  time  to  time  micrococci  and  the  products  of  their  metabolism 


384  INPLAMMATIOX  AND  INJURIES. 

escape  from  some  particular  focus  or  collection  of  them  into  the  gen- 
eral circulation.  AVhen  their  metaholic  products  have  again  been  ex- 
creted from  the  blood  the  fever  ceases. 

The  condition  of  the  pulse  corresponds  to  the  course  of  the  fever, 
but  Kouig  is  right  in  stating  that  the  pulse  of  a  pyaemic  patient  still 
remains  rapid  during  the  time  when  there  is  no  fever,  and  never  en- 
tirely falls  to  the  normal  rate.  The  general  condition  of  the  patient 
varies  with  the  amount  of  the  fever.  The  appetite  is  usually  very 
poor ;  occasionally  there  is  nausea  or  vomiting,  and  in  the  later  stages 
there  is  apt  to  be  a  profuse  diarrhoea.  The  urine  ordinarily  contains 
albumen  and  casts.  Jaundice  is  common,  and  is  sometimes,  as  in  sep- 
ticsemia,  hsematogenous,  in  consequence  of  the  disintegration  of  the 
red  blood-corpuscles ;  and  in  other  cases  it  may  be  caused  by  pyaemic 
abscesses  of  the  liver  or  by  catarrhal  swelling  of  the  intestinal  mucous 
membrane  in  the  neighbourhood  of  the  ductus  choledochus.  The  other 
symptoms  of  pyaemia  are,  in  general,  caused  by  the  metastatic  inflam- 
mations in  the  internal  organs,  and  vary  greatly  according  to  the  ex- 
tent and  location  of  these  inflammations.  Metastases  in  the  lungs  give 
rise  to  hgemoptysis,  to  circumscribed  catarrhal  processes,  to  lobular 
pneumonia,  extensive  pulmonary  abscesses,  and  to  tiie  different  kinds 
of  pleural  inflammation.  The  metastatic  processes  in  the  abdominal 
organs,  the  liver,  spleen,  and  kidneys,  often  give  rise  to  so  few  symp- 
toms that  they  cannot  be  diagnosticated  during  the  life  of  the  patient. 
Abscesses  occur  with  the  greatest  frequency  in  the  lungs  and  spleen, 
less  often  in  the  liver  and  kidneys.  Metastatic  joint  inflammations  are 
not  uncommon.  A  large  amount  of  albumen  in  the  urine,  with  epithe- 
lium, casts,  and  an  admixture  of  blood,  indicate  an  acute  metastatic 
nephritis. 

If  metastatic  suppuration  develops  in  the  brain  there  will  be  corre- 
sponding symptoms  of  paralysis.  Metastatic  meningitis  will  present 
the  picture  of  diffuse  snppui-ative  encephalitis. 

The  abscesses  which  may  occur  in  the  superficial  organs,  the  lymph 
glands,  parotid,  joints,  muscles,  and  subcutaneous  cellular  tissue,  etc., 
are  easily  recognisable  ;  they  often  cause  no  pain,  and  are  accompanied 
with  little  inflammatory  reaction,  which  is  also  the  case  with  abscesses 
in  the  medulla  of  the  bones.  As  in  septicaemia,  there  is,  in  consequence 
of  the  disturbance  of  nutrition  in  the  walls  of  the  vessels,  a  tendency  to 
capillary  haemorrhages  ;  or,  in  consequence  of  the  suppurative  breaking 
down  of  a  thrombus  and  the  adjoining  wall  of  the  vessel,  which  may 
be  situated  within  a  focus  of  suppuration,  haemorrhages  from  the  larger 
arteries  and  veins  may  take  place,  which  will  endanger  the  life  of  the 
patient.     The  eruptions  on  the  skin  are  to  be  explained  either  as  bac- 


§  75.]  PYAEMIA.  385 

terial  metastases  in  the  skin  or  as  angioneuroses  due  to  the  action  of  the 
bacterial  toxiues  (R.  Meyer).  If  the  pyaemia  starts  from  a  granu- 
lating wound,  it  is  sometimes  noticed  that  the  latter  begins  to  sup- 
purate less  freely  than  before,  the  granulations  become  pale  and  flabby, 
and  not  infrequently  break  down  or  undergo  diphtheritic  changes. 

The  duration  of  a  py?emia  is  very  uncertain.  Generally  it  runs  an 
acute  course  (eight  to  ten  to  twelve  days),  often  a  subacute  (three  to 
four  weeks),  less  frequently  a  chronic  course  (two  to  three  to  five 
monthsj.  As  in  septicsemia,  so  also  in  pysemia  there  are  cases  which 
apparently  recover  and  then  suddenly,  after  the  lapse  of  months  or  a 
year  or  more,  there  occurs  a  fresh  acute  general  infection  starting  from 
the  old  encapsulated  pysemic  focus,  to  which  the  patient  may  succumb. 
The  prognosis  of  pyaemia  depends  in  general  upon  whether  the  local 
infection  can  be  promptly  overcome  or  not. 

Prognosis  of  Pyaemia. — Acute  pyaemia  is  usually  fatal,  and  yet  there  are 
recorded  cases  of  recovery  in  spite  of  internal  metastases  in  the  lungs,  spleen, 
etc.  The  more  frequently  the  chills  are  repeated,  the  more  rapidly  the 
strength  fails,  and  tlie  earlier  the  symptoms  occur  pointing  to  internal  metas- 
tases, so  much  the  more  rapidly  will  the  disease  terminate  in  death.  Chronic 
pyaemia  finally  kills  the  j^atient  by  exhaustion,  unless  the  focus  of  infection 
that  is  present  is  subjected  to  proper  surgical  treatment. 

Diagnosis. — In  the  diagnosis  of  pyaemia  the  irregular  course  of  the  fever, 
with  intercurrent  chills  and  the  occurrence  of  metastases,  are  almost  pathog- 
nomonic. Occasionally  jjya^mia  is  combined  with  septicaemia  or  with  ery- 
sipelas, and  then  its  course  is  masked  by  the  other  infectious-wound  disease. 

Treatment  of  Pyaemia.— Pyaemia  is  treated  in  essentially  the  same 
way  as  septicaemia.  As  in  septicaemia,  the  local  treatment  of  the  source 
of  infection  is  exceedingly  important,  and  should  be  as  energetic  as 
possible — that  is,  every  pyaemic  collection  of  pus  should  be  done  away 
with  at  the  earliest  possible  moment.  All  metastatic  abscesses  accessible 
to  surgical  treatment  should  be  opened  on  antiseptic  principles  and  dis- 
infected. But  the  treatment  of  fully  developed  pyaemia,  as  of  septicse- 
mia,  is,  for  the  most  part,  of  no  avail.  It  must,  however,  never  be  for- 
gotten that  we  have  a  certain  means  of  preventing  both  diseases  by 
practising  thorough  antisepsis  in  the  treatment  of  every  wound.  If  the 
patient  is  long  confined  to  bed,  disturbances  of  the  circulation,  as  a 
result  of  cardiac  and  respiratory  weakness,  are  very  apt  to  occur  in  the 
skin,  followed  by  necrosis  of  the  latter — in  other  words,  bedsores  or  de- 
cubitus may  appear,  especially  in  those  regions  where  the  skin  is  closely 
superimposed  upon  the  bones,  as  over  the  sacrum,  the  trochanters,  scap- 
ulae, and  elbows.  To  avoid  this  complication,  these  areas  of  skin  should 
be  carefully  protected  from  pressure  by  the  use  of  air-  or  water- 
cushions,  and  they  should  be  kept  scrupulously  clean  by  washing  them 
27 


386  INFLAMMATION  AND   INJURIES. 

with  alcohol,  etc.  The  treatment  of  bedsores  after  tliej  have  devel- 
oped will  be  discussed  under  the  subject  of  ulcers  (see  §  93,  Diseases  of 
the  Skin). 

§  76.  Infection  by  Cadaveric  Poison. — All  individuals  who  have  much 
to  do  with  cadavers  or  dead  animal  matter,  and  so  all  physicians,  anato- 
mists, butchers,  cooks,  etc.,  are  liable,  on  the  reception  often  of  trilling 
injuries,  to  suffer  from  infectious  inflammations  of  various  sorts,  which 
very  often  lead  to  fatal  general  poisoning.  The  so-called  cadaveric 
poison  is  more  or  less  identical  with  the  poison  of  decomposition.  But 
the  bodies  of  all  animals  which  have  died  from  a  specific  infectious- 
wound  disease,  such  as  erysipelas,  pyaemia,  anthrax,  rabies,  etc.,  still 
harbour  the  specific  bacteria  which  caused  this  infectious  disease,  and 
these  bacteria  remain  capable  of  exciting  the  same  disease  for  the 
first  twenty -four  hours  after  death.  When  decomposition  of  the  dead 
body  sets  in,  the  specific  bacteria  of  pyaemia,  erysipelas,  anthrax,  etc., 
perish,  succumbing  in  the  struggle  for  existence  with  the  bacteria  of 
decomposition.  Consequently  there  may  be  various  poisonous  sub- 
stances in  the  cadaver,  notably  the  excitants  and  products  of  decompo- 
sition, and  also,  in  the  period  immediately  following  death,  the  excitants 
of  specific  diseases.  Therefore  it  can  be  understood  why  the  infections 
of  wounds  from  dead  bodies  have  vei-y  different  clinical  results,  and 
that  septicasmia  and  pyaemia,  as  well  as  specific  diseases  like  antlirax 
and  tuberculosis,  are  alike  transmissible  from  cadavers.  Infection  with 
cadaver  poison  usually  takes  place  through  a  small  incised  or  punctured 
wound,  an  abrasion  of  the  skin  from  a  splinter  or  sharp  edge  of  bone, 
etc.,  and  frequently  the  injury  is  so  trifling  as  not  to  bleed,  and  may  be 
entirely  overlooked.  As  a  general  thing  it  is  better  when  the  wound 
bleeds,  as  then  any  bacteria  which  may  have  lodged  in  it  are  apt  to  be 
swept  out  by  the  flow  of  blood. 

In  the  first  place,  there  are  wound  infections  which  run  a  very  acute 
course,  particularly  those  in  which  the  infection  is  from  a  septic  cadaver. 
This  may  also  occur  in  surgeons  after  they  have  oj^erated  upon  a  col- 
lection of  foul  pus  in  a  living  patient.  The  septic-wound  infection 
may,  in  the  worst  cases,  exhibit  the  following  peculiarities :  At  the 
outset  there  is  a  small  injuiy,  which  generally  causes  only  a  slight 
amount  of  pain,  and  then  very  soon  there  occur  headache,  nausea,  gen- 
eral lassitude,  a  severe  chill,  and  a  rapid  rise  of  temperature.  In  the 
worst  cases,  which  are,  however,  not  common,  death  may  follow  with- 
in two  to  three  days,  preceded  by  delirium  and  stupor,  and  yet  the  point 
where  infection  took  place  will  not  show  any  noticeable  local  inflam- 
mation. These  are  the  cases  of  acute  septicaemia  which  have  been 
described  in  §  74.      It  is  still  a  question  whether  these  severe  forms  of 


§  76.]  INFECTION  BY   CADAVERIC   POISON.  387 

septicsemia  can  be  caused  by  infection  from  a  non-septic  cadaver — i.  e., 
by  infection  with  the  usual  cadaveric  poison. 

Comparatively  often,  after  infection  from  a  dead  body,  a  circum- 
scribed inflammation  will  begin  in  the  neighbourhood  of  the  wound, 
terminating  in  suppuration,  and  having  a  tendency  to  gangrene,  with 
secondary  lymphangitis,  phlebitis,  and  purulent  lymphadenitis,  for 
example,  in  the  e23itrochlear  and  axillary  glands.  Sometimes  the  course 
of  the  disease  is  very  protracted,  and  there  are  cases  which  act  like 
chronic  pygemia.  These  latter  are  apt  to  occur  after  infection  from  the 
dead  body  of  a  patient  who  has  died  of  pyaemia. 

Cadaver  Tuberculosis  (  Verruca  necrogenica). — The  so-called  ana- 
tomical tubercle  is  a  peculiar  chronic  form  of  infection  from  dead 
bodies,  and  is  the  name  given  to  Avart-like,  moist,  often  ulcerating 
growths,  which  are  particularly  liable  to  occur  upon  the  backs  of  the 
hands  or  the  knuckles  of  those  who  habitually  handle  cadavers,  such  as 
anatomists,  demonstrators,  etc.  The  anatomical  tubercle  usually  re- 
mains local,  though  there  may  be  attacks  of  acute  lymphangitis  and 
lymphadenitis,  with  possibly  the  formation  of  abscesses.  Baumgarten, 
Eiehl,  and  others  have  demonstrated  that  the  anatomical  tubercle  is  not 
the  result  exclusively  of  ordinary  cadaver  poisoning,  as  these  investiga- 
tors have  found  tubercle  bacilli  in  the  tubercles.  Consequently  it  is 
an  undoubted  fact  that  some  anatomical  tubercles,  at  least,  are  forms 
of  local  tuberculosis. 

Thei^e  occasionally  result  from  cadaver  infection  small  abscesses 
and  pustules  without  any  injury  of  the  skin  having  occurred  ;  under 
these  conditions  the  poisonous  substances  are  lodged  in  the  normal 
cutaneous  pores,  especially  the  sebaceous  glands. 

Zoonotic  Erysipeloid. — In  this  class  of  cases  belongs  the  so-called 
zoonotic  Jinger-erysipeloid — chronic  erysipelas  or  erythema  migrans — 
which  has  been  described  on  page  357. 

Mention  has  been  made  of  the  fact  that  very  dangerous,  specific, 
infectious-wound  diseases  can  be  transmitted  to  man  from  the  dead 
bodies  of  human  beings  and  animals,  particularly  within  the  first 
twenty-four  hours  following  death.  This  matter  will  be  discussed 
again  when  we  come  to  the  subjects  of  anthrax,  syphilis,  etc. 

Prophylaxis  and  Treatment  of  Cadaver  Infection. — From  these  facts 
it  follows  that  every  one  having  much  to  do  with  dead .  human  or 
animal  bodies  should  use  the  greatest  precautions.  To  jprevent  cadav- 
eric infection,  the  hands  should  be  thoroughly  disinfected  in  the  way 
described  on  pages  10  and  12.  By  this  means  the  so-called  anatom- 
ical tubercle  can  be  avoided  with  certainty,  and  after  it  has  broken  out 
it  can  be   caused   to   gradually  disappear  by  the   use   of  bichloride 


388 


INFLAMMATION  AND  INJURIES. 


washes  and  dressings.  If  post-mortem  examinations  have  to  be  under- 
taken upon  bodies  infected  with  pyaemia,  septicaemia,  anthrax,  etc.,  or 
in  case  of  small  scratches  or  wounds  of  the  hand,  it  is  an  excellent  plan 
to  cover  the  hands  with  carbolised  vaseline,  rubber  gloves,  etc. 

If  an  injury  is  sustained  during  the  autopsy  the  blood  should  l)e 
pressed  out  of  the  wound,  or  the  latter  should  be  sucked  and  then 
thoroughly  disinfected,  no  matter  how  trilling  it  may  be,  with  a  one- 
fifth -per-cent.  solution  of  bichloride  of  mercury,  or  a  five-per-cent. 
solution  of  carbolic  acid.  These  remedies  are  better  than  the  appli- 
cation of  caustic  acids  which  form  an  eschar,  such  as  nitric  acid, 
which  was  at  one  time  very  frequently  used.  After  many  years' 
experience  as  an  anatomist,  Louge  advises  that  before  undertaking 
an  autopsy  all  cracks  or  scratches  on  the  hands  should  be  painted  with 
tincture  of  iodine ;  and  he  has  also  adopted  the  same  treatment  for 
any  wound  received  during  the  course  of  the  autopsy,  after  it  has 
stopped  bleeding.  If  local  inflammation  or  systemic  infection  should 
occur,  either  condition  should  be  treated  upon  the  principles  which 
have  been  laid  down  in  a  previous  chapter.  Long  and  deep  incisions 
should  always  be  made  at  an 

early  stage  at  the  point  of  in-  '^"'''''     ^^^''^^^'^''^''^ 

fection,  and  these  should  be  "'*'*^>*^^^ih 

followed  by  the  continuous  ap-  ""'    >a^<^^^^ 

plication   of   solutions   of   bi-  "''^f^^0^"" 


Fig.  820. — Blood  from  a  mouse  infected 
with  anthrax ;  red  corpuscles  and  an- 
thrax bacilli.  The  latter  are  stained 
with  methylene  blue,     x  800. 


Fig.  321. — Anthrax  threads  from  the  blood  of  a 
mouse.  Taken  from  a  bouillon  culture  ten  hours 
old  at  24°  C  At  a  the  threads  are  .seen  dis- 
tinctly to  be  made  up  of  separate  bacilli,    x  TOO. 


chloride  of  mercury  varying  in  strength  from  1  to  500  to  1  to  1,000 
of  water,  acetate  of  aluniinium  1  to  2  per  cent.,  etc.  Morphine  should 
be  exhibited  hypodermically  to  alleviate  pain. 

§  77.  Splenic  Fever  or  Anthrax. — Anthrax  is  an  acute  infectious 
disease  caused  by  a  specific  bacillus,  and  is  one  of  the  most  widely  dis- 
tributed and  fatal  of  diseases,  particularly  among  cattle,  and  it  is  not 
infrequently  communicated  from  them  to  man.     The  name  sjjleyiio 


77.] 


SPLENIC  FEVER  OE  ANTHRAX. 


389 


fever  is  derived  from  the  fact  that  animals  afflicted  with  this  disease 
have  a  verj  much  enlarged  spleen. 

Etiology  of  Anthrax.— Accurate  knowledge  had  been  obtained  about  the 
origin  of  anthrax  before  anything  was  known  about  the  etiology  of  the 
other  bacterial  infectious  diseases.  In  1849  Pollender  and 
Brauell,  working  entirely  independently  of  each  other,  dis- 
covered in  the  blood  of  cattle  dying  of  anthrax,  fine  rod- 
shaped  structures,  and  afterwards  recognised  their  vegetable 
nature.  Davaine  was  the  first  to  prove  that  anthrax  could 
not  be  excited  in  healthy  animals  by  inoculating  the  latter 
with  blood  which  contained  no  bacteria,  but  that  it  could  be 
produced  by  inoculations  with  blood  in  which  the  bacilli 
were  present  (1863).  These  experiments  were  frequently  re- 
peated, and  always  with  the  same  results,  Pasteur,  in  par- 
ticular, using  blood  which  had  been  freed  from  formed  ele- 
ments by  filtering  it  through  porcelain.  Robert  Koch  has 
furnished  us  with  the  most  important  facts  concerning  an- 
thrax and  its  bacilli. 

Anthrax  Bacillus.— The  anthrax  bacillus  {bacillus  an- 
thracis)  is  a  transparent  rod,  incapable  of  motion,  possesses 
rounded  ends,  and  is  3  to  10  ^  long  and  1.0  to  1.2  /*  broad 
(Fig.  320).  It  is  found  in  the  blood  of  animals  suffering 
from  anthrax  either  singly,  each  bacillus  by  itself,  or  in  fila- 
ments made  up  of  two  to  six  to  ten  little  rods  connected 
together  (Fig.  321).  The  line  of  separation  between  the  indi- 
vidual bacilli  is  often  plainly  distinguishable,  causing  the 
anthrax  filaments  to  assume  a  characteristic  appearance. 
The  bacillus  is  incapable  of  motion  and  is  aerobic — that  is, 
it  requires  the  presence  of  oxygen  to  grow,  the  most  favour- 
able temperature  being  that  obtained  in  a  culture  oven,  and 
no  development  takes  place  below  15°  C.  or  above  45°  C. 
The  gelatine  is  rapidly  liquefied.  Gelatine  puncture  cul- 
tures usually  present  the  appearance  illustrated  in  Fig.  322 
— that  is,  fine  processes,  thorns,  or  needles  radiate  from  the  line  in  which  the 
puncture  was  made.  On  gelatine  plates  colonies  develop  with  a  notched, 
uneven  border  or  a  cone-shaped  coil,  from  which  filamentous  extensions 
stretch  out  in  all  directions.  On  potatoes  the  bacillus  forms  a  dry,  white 
layer  (Fig.  323) ;  on  agar  there  develops  a  greyish,  slightly  glistening  cover- 
ing. In  all  artificial  nutritive  media  long  filaments  are  formed  made  up  of 
many  hundreds,  or  even  thousands,  of  sepai-ate  bacilli.  When  the  nutrition 
has  become  exhausted  from  the  culture  medium,  provided  oxygen  is  present 
and  the  temperature  remains  between  18°  and  40°  C,  the  bacilli  develop 
spores,  which  have  the  shape  of  small  drops  with  a  strongly  refractive 
power.  The  best  spores  form  in  temperatures  between  20°  to  25°  C.  At  the 
most  favourable  temperature  the  spores  are  formed  in  twenty-four  hours ; 
at  21°  C.  it  takes  seventy  to  seventy-five  hours.  After  the  spores  have 
fully  formed  the  bacillus  breaks  up,  and  the  spores  are  liberated  and  can 
then,  if  they  lodge  upon  a  proper  nutritive  medium,  each  groAv  into  a  bacil- 


FiG.  322. —  Stab 
culture  of  an- 
thrax in  gela- 
tine. Eight 
days  old. 


390 


INFLAMMATION   AND   INJURIES. 


lus.     The  powers  of  resistance  possessed  by  anthrax  spores  vary  with  tlie 
particular  noxious  intiuence  to  which  they  may  be  subjected,  a  five-per-cent. 
solution  of  carbolic  acid,  for  instance,  killing  them  in  two  to  thirty  to  fifty 
days,  while  steam  at  a  ten)perature 
of  100°  C.  will  destroy  their  vitality 
in  three  to  ten  to  twelve  minutes. 


Fig. 


523. — fure  culture  of  anthrax  bacilli 
upon  a  boiled  potato. 


Fir 


32-i. — Anthrax  threads  containing  spores. 
X  800. 


If  bichromate  of  potassium,  in  the  proportion  of  1  to  2.000-5,000.  is  added  to 
a  nutritive  medium  containing  anthrax,  such  as  bouillon,  the  bacilli  will  lose 
their  power  of  forming  spores.  The  same  result  can  be  obtained  by  subject- 
ing bouillon  cultures  containing  carbolic  acid  (in  the  proportion  of  8  to  20- 
10,000)  for  eight  days  to  a  temperature  ranging  between  30°  and  33°  C. 
Anthrax  bacilli  thus  rendered  incapable  of  forming  spores  lose  none  of  their 
virulence  when  used  for  inoculating  purposes  ;  nevertheless,  the  species  never 
regains  its  lost  power  of  developing  spores.    There  is  some  difference  between 

the  shape  and  the  appearance  of  the  cultures  of 
the  ordinaiw  anthrax  bacilli  and  those  rendered 
incapable  of  spore  formation.  This  fact  has 
peculiar  significance,  showing,  as  it  does,  that 
the  bacteria  exhibit  marked  differences  depend- 
ing upon  the  medium  in  which  they  develop, 
and  that  they  cannot  be  distinguished  from  one 
another  without  taking  other  things  into  ac- 
count besides  their  shape  and  the  appearance  of 
the  culture.  When  they  have  exhausted  the 
nutritive  principles  from  any  medium  in  which 
they  are  growing  the  bacilli  die  or  take  on  in- 
volution forms.  The  anthrax  bacilli  develop  no 
.spores  in  the  living  animal  body  and  in  the 
undecomposed  cadaver,  as  this  jjrocess  ^vill  only 
take  place  when  the  access  of  oxygen  is  unhindered. 

The  best  way  to  study  the  development  of  the  bacilli  under  the  micro- 
scope is  to  place  a  drop  of  the  ordinary  culture  bouillon  containing  the  bacilli 
in  the  concavitv  of  a  slide. 


Fio.  325. — Anthrax  spores  from  a 
culture  twenty-four  houi-s  old. 
The  spores,  which  are  stained 
red  witli  fuchsin,  are  partly 
free  and  partly  within  the  ba- 
cilli stained  with  methylene 
blue.     (See  also  Ficr.  264.) 


§  77.]  SPLENIC   FEVER   OR   ANTHRAX.  391 

Artificial  Attenuation  of  the  Virulence  of  Anthrax  Bacilli.— The  viru- 
lence of  anthi'ax  bacilli  can  be  weakened  or  attenuated  in  various  ways,  such 
as  subjecting  them  to  a  high  or  low  temjjerature,  or  making  the  culture  gi'ow 
for  a  long  time — twenty-four  days  or  so — at  a  temperature  of  42°  to  43°  C. 
By  treating  them  in  some  such  manner  it  is  possible  to  render  anthrax 
bacilli  entirely  innocuous  (Koch,  Loffler,  etc.). 

By  cultivating  them  in  bouillon  made  of  fresh  blood  from  guinea-pigs 
the  lost  virulence  can  be  restored  (Chauveauj.  The  attenuated  bacillus  forms 
metabolic  products,  which  differ  from  those  of  vii'ulent  anthrax,  the  latter 
producing  on  artificial  nutritive  media  large  amounts  of  acid,  while  the 
former  is  more  prone  to  form  alkaline  substances  (Behriug). 

The  virulence  of  anthrax  bacteria  can  be  weakened  by  various  antagonis- 
tic bacteria,  such  as  the  cocci  of  erysipelas,  the  Bacillus  pyocyaneus,  Fried- 
lander's  pneumococcus.  the  Micrococcus  prodigiosus,  the  Bacillus  putidus 
and  albus,  etc.  Baumgarten  and  others  found  that  when  the  Staphylococcus 
pyogenes  aureus  comes  in  contact  with  anthrax  bacilli  in  the  bodies  of  mice 
and  guinea-pigs,  the  former  increases  very  much  in  virulence  and  causes  a 
fatal  septicaemia,  while  at  the  same  time  the  development  of  the  anthrax 
bacilli  is  completely  arrested.  Also,  sterilised  cultures  of  these  antagonistic 
bacteria  exert,  according  to  Buchner,  a  restraint  ujion  the  development  of 
anthrax  bacilli,  whence  it  follows  that  the  chemical  substances  derived  from 
the  above-mentioned  bacteria  are  the  active. restraining  agents.  These  facts 
concerning  the  attenuation  of  anthrax  bacilli  have  been  made  use  of  for 
bi'inging  about  artificial  immunity  against  virulent  anthrax  bacilli.  Pasteur 
tried  to  make  cattle  and  sheep  susceptible  to  anthrax  by  inoculating  them 
with  bacilli  which  had  been  attenuated  by  cultivation  at  a  temperature  of 
42°  to  43°  C  The  principle  is  the  same  as  in  vaccination  with  cow-pox  for 
protection  from  variola  ;  but  Pasteur's  inoculation  with  attenuated  anthrax 
does  not  always  seem  to  give  immunity  from  infection  occurring  in  the 
ordinary  way  through  the  intestine.  Hankin,  in  Koch's  institute,  isolated  a 
poisonous  albumose  from  anthrax  cultures,  which  produced  in  mice  and 
rabbits  immunity  from  anthrax  when  exhibited  in  very  small  doses.  Em- 
merich, Di  Mattei,  and  others  inoculated  animals  (rabbits)  with  the  erysipelas 
coccus,  and  they  became  afterwards  unsusceptible  to  anthrax.  Emmerich 
has  prepared  a  germ-free  serum  from  sheep  infected  with  erysipelas-strep- 
tococci for  the  treatment  of  anthrax  in  man.  The  discovery  made  by  Wool- 
dridge  is  exceedingly  interesting.  He  found  that  injections  of  a  solution  of 
fi.brinogen  which  had  been  used  for  the  cultivation  of  anthrax  made  ani- 
mals immune  from  this  disease,  and  that  the  same  result  could  also  be  ob- 
tained by  using  fibrinogen  which  had  been  subjected  to  a  slight  chemical 
change  without  making  use  of  anthrax  bacilli.  Charrin  and  Bouchard  have 
checked  anthrax  at  its  inception  in  animals  by  inoculating  them  with  the 
Bacillus  pyocyaneus,  and  have  cured  the  disease. 

Most  authors  are  of  the  opinion  that  anthrax  bacilli  lose  .some  of  their 
virulence  after  having  passed  through  the  body  of  an  animal  which  is  not 
susceptible  to  them.  On  the  other  hand.  Malm  was  able  to  show  that  their 
virulence  is  increased. 

Occurrence  and  Origin  of  Anthrax. — xlnthrax  is  widely  distributed  in 
many  countries,  such  as  Russia,  Siberia,  Hungai'y,  India,  Persia,  and  in  certain 


392 


INFLAMMATION  AND   INJURIES. 


^^v 


€;*i 


Fig.  326. — Anthrax  bacilli 
from  a  mulijjnant  pus- 
tule of  the  skin.  The 
bacilli  are  stained  with 
gentian  violet,  and  the 
tissues  with  Bismarck 
brown,     x  300. 


districts  of  France  and  Germany,  and  yearly  works  destruction  in  herds  of 
cattle,  particularly  during  the  hot  summer  montlis,  while  in  winter  it  ceases 
X  its  ravages.     In  England  and  North  America  anthrax 

is  not  so  common.  The  anthrax  bacillus  has  not  yet 
been  jiroved  to  exist  outside  of  the  animal  bod3\  In 
grazing  animals  (.slieep,  cattle,  horses)  the  bacillus  is 
most  commonl}^  taken  into  the  system  througli  the 
intestine,  less  often  by  cutaneous  inoculation.  Mice, 
guinea-pigs,  and  rabbits  are  easily  infected  by  inhal- 
ing the  spores,  and  are  not  readily  infected  through 
the  intestine.  In  man,  anthrax  is  communicated  jjar- 
ticularly  by  infection  of  small  cutaneous  wounds 
(malignant  pustule),  less  often  through  the  lungs  and 
intestine.  The  anthi'ax  bacilli  multiply  very  rapidly 
in  the  animal  body,  and  are  found  not  only  at  the 
point  of  infection — the  malignant  pustule,  for  exam- 
ple (Fig.  326) — but  also  in  the  blood-vessels,  where 
they  exist  in  vast  numbers.  They  are  also  present,  immediately  after  the 
infection  takes  place,  in  the  lymph  and  the  chyle  Avhen  the  infection  occurs 
through  the  intestine.  In  the  malignant  pustule  the  anthrax  bacilli  will  be 
fi'equently  found  enclosed  within  cells,  a  fact  which  cannot  be  considered  as 
supporting  Metschnikoff's  theory  of  phagocytosis  (see  pages  276,  277),  as  the 
bacilli  were  probably  dead  before  they  were  taken  up  by  the  cells.  The 
infected  organism  usually  succumbs  very  soon  in  consequence  of  the  rapid 
multiplication  of  the  bacilli  and  the  poi- 
sonous products  of  their  metabolism.  The 
toxic  products  (albumoses  and  bases)  of 
the  anthrax  bacilli  have  been  studied  by 
Hankin,  Lando  Landi,  and  others. 

Natural  Immimity  of  certain  Animals 
from  Anthrax. — Dogs,  pigs,  and  the  ma- 
jority of  birds,  are  immune  from  anthrax  ; 
also  rats,  for  the  most  part,  and  frogs 
under  ordinary  conditions.  But  if  a  frog, 
in  whose  lymph  sac  are  placed  anthrax 
spores,  is  put  in  an  incubation  apparatus, 
he  will  quickly  die  of  anthrax.  Accoi'd- 
ing  to  Rohrschneider,  28°  C.  is  the  lowest 
limit  of  temperature  at  which  anthrax 
bacilli  will  develop  within  a  frog's  body. 
According  to  Crookshank,  pigs  may  ac- 
quire anthrax.  Ssawtschenko  stated  that 
after  the  spinal  cord  is  divided  in  doves 
they  are  no  longer  immune  from  an- 
thrax.    In  general,  the  immunity  which 

various  animals  possess  towards  anthrax  does  not  appear  to  be  complete,  as 
the  bacilli  can  gradually  become  accustomed  to  develop  in  media  which 
are  unsuitable  for  them. 

It  has  been  proved  by  Birch-Hirschf eld  and  others  that  anthrax  bacilli 


Fig.  327. — Anthrax  bacilli  in  the  capilla- 
ries of  an  intestinal  villus  (rabbit), 
stained  with  methylene  violet  and 
then  treated  with  j)otassium  carbon- 
ate.    X  800. 


§  77.]  SPLENIC   FEVER  OR  ANTHRAX.  393 

can  be  transmitted  from  the  mother  to  the  foetus  in  utero.  The  bacilli,  as  it 
were,  grow  into  the  foetal  placenta,  aided  by  changes  in  the  walls  of  the  ves- 
sels, in  the  tissues  surrounding  the  vessels,  and  in  the  epithelium  of  the  villi. 
The  healthy  placenta  does  not  normally  permit  the  passage  into  and  through 
it  of  micro-organisms  or  other  formed  elements,  and  the  filter  only  becomes 
pervious  when  affected  by  pathogenic  bacteria  which  have  gained  access  to 
the  placenta. 

Staining  of  Anthrax  Bacilli.— The  anthrax  bacillus  can  be  rapidly  stained 
by  aqueous  solutions  of  the  aniline  dyes,  and  also  by  Gram's  method.  The 
spores  are  best  stained  at  a  high  temperature  by  means  of  Ehrlich's  aniline- 
water-fuchsin  solution  or  Ziehl's  solution  containing  carbolic  acid.  Instead 
of  Ehrlich's  fuchsin  solution,  a  correspondingly  made  solution  of  gentian 
violet  can  be  employed  for  staining  the  spores.  After  decoloration  of  the 
substance  of  the  bacilli  the  spores  are  stained  with  Bismarck  brown. 

The  Course  of  Anthrax  in  Animals.— Anthrax  in  domestic  animals  may 
take  one  of  three  courses :  1,  The  apoplectiform  anthrax  (anthrax  acutis- 
simus),  which  lasts  from  a  few  minutes  to  several  hours ;  2,  the  acute  an- 
thrax (anthrax  acutus),  lasting  from  a  few  hours  to  several  days ;  and, 
3,  the  subacute  form  of  anthrax  (anthrax  subacutus),  of  longer  duration. 
There  is  no  period  of  incubation,  or  it  may  occupy  three  to  five  days.  In 
the  more  common  apoplectiform  variety  of  anthrax  (cattle,  sheep)  the  animals 
which  previously  had  apparently  been  in  perfect  health  fall  down  as  though 
struck  with  a  blow,  and  die  often  in  a  few  minutes  with  convulsions,  cyanosis, 
and  dyspnoea.  According  to  Bollinger,  acute  anthrax  in  cattle  and  horses 
begins  with  loss  of  appetite  and  a  chill,  followed  by  a  remittent  or  inter- 
mittent high  fever  (41°  C. — 105.8°  F. — and  higher)  ;  there  are  almost  always 
spasms,  particularly  clonic  spasms  of  the  extremities.  These  symptoms  come 
on  in  the  form  of  paroxysms.  The  subacute  form  of  anthrax,  the  anthrax 
carbuncle,  is  characterised  by  carbunculous  and  erysipelatous  swelling  oc- 
curring in  different  places  in  the  skin,  particularly  in  the  region  of  the  hind 
feet,  while  there  is  only  a  slight  constitutional  disturbance.  The  carbuncle 
begins  to  be  absorbed  frequently  after  the  lapse  of  a  few  days,  and  an  eschar 
and  ulceration  develop  only  exceptionally.  In  about  sixty  to  seventy  per 
cent,  of  the  subacute  cases  (in  cattle  and  horses,  for  example)  death  follows 
with  dyspnoea  and  convulsions. 

Anthrax  in  Man. — Anthrax  occurs  in  man  mainly  by  transmission 
of  the  anthrax  bacilli  or  their  spores  from  a  diseased  animal,  and  hence 
those  persons  are  particularly  liable  to  the  disease  who  in  their  occupa- 
tion come  in  contact  with  infected  animals  or  parts  of  animals.  Such 
persons  are  shepherds,  farmers,  butchers,  veterinary  surgeons,  workers 
in  leather  (furriers,  and  those  who  handle  skins),  and  people  who  are 
employed  in  the  preparation  of  horse-hair,  wool,  and  paper. 

The  so-called  rag-sorters'  disease,  which  runs  a  rapidly  fatal  course, 
presenting  the  appearance  of  pneumonia  with  typhoid  or  septic  symp- 
toms, and  attacks  people  who  sort  and  tear  rags  in  the  manufacture  of 
paper,  is  occasionally  primary  anthrax  of  the  lungs  caused  by  inhaling 


394  INFLAMMATION  AND   INJURIES. 

anthrax  spores.  Kraunhals  states  that  tlie  disease  is  also  caused  bj  the 
bacilhis  of  raahgnant  oedema.  There  is  a  great  variety  of  micro- 
oro-anisras  in  rags.  O.  Roth  describes  three  kinds  of  pathogenic  bacilli : 
Bacillus  I  is  like  the  Bacterium  coll,  Bacillus  II  like  the  Proteus  homi- 
nis,  and  Bacillus  III  like  Hauser's  Proteus  vulgaris  (see  page  373). 

Enderleu's  experiments  in  the  Pathological  Institute  at  Munich 
show  that  breathing  in  the  spores  of  anthrax  is  much  more  dangerous 
than  their  ingestion  in  food.  All  "  inhalation  animals "  perished  of 
anthrax,  while  of  the  animals  infected  through  food  some  remained 
alive.  Anthrax  is  also  caused  in  man  by  eating  the  flesh,  milk,  or  but- 
ter obtained  from  animals  affected  with  this  disease.  It  may  also  be 
transmitted  by  insects  (flies)  which  come  in  contact  with  animals  having 
anthrax,  and  the  poison  may  be  comnmnicated  from  man  to  man — for 
example,  at  an  autopsy.  The  disease  starts  either  by  inoculation  of  the 
bacilli  or  of  their  spores  into  the  skin  (it  may  be  a  very  small  interrup- 
tion of  continuity),  or  by  inhalation  of  the  poison,  or  by  its  introduction 
with  the  food  into  the  alimentary  canal.  The  cases  of  so-called  intes- 
tinal mycosis  recorded  by  E.  Wagner  and  others  are  really  cases  of 
true  anthrax  disease.  In  general  man  is  only  slightly  disposed  towards 
anthrax.  Marchand  observed  anthrax  in  a  pregnant  woman  with  fatal 
infection  of  the  child.  Lingard,  experimenting  with  pregnant  rabbits, 
caused  an  infection  of  the  foetus,  and  found  that  in  some  cases  the 
foetus  alone  became  diseased,  in  others  the  mother  also.  Sections 
through  the  placenta  plainly  showed  the  passage  of  the  anthrax  bacilli 
from  the  foetal  to  the  maternal  blood-vessels.  Birch-Hirschfeld's  re- 
cent observations,  which  were  mentioned  before,  are  very  interesting, 
proving,  as  they  do,  the  transmission  of  the  anthrax  bacilli  from  the 
maternal  into  the  fojtal  circulation.  If  an  abundant  development  of 
anthrax  bacilli  takes  place  in  the  placenta,  the  bacteria  actually  grow 
into  and  through  the  foetal  portion  of  the  placenta  in  a  manner  similar 
to  that  in  which,  after  inhalation  of  anthrax  spores,  the  bacilli  enter 
the  pulmonary  vessels,  as  was  demonstrated  by  Buchner's  experiments. 

The  course  which  anthrax  takes  in  man  varies  according  to  whether 
the  infection  takes  place  externally  or  internally.  When  infection  oc- 
curs through  the  skin  there  is  an  incubation  period  of  three  to  six 
days,  and  then  at  the  point  of  entrance  there  develops  a  burning  or 
itching  red  nodule  Tvath  a  reddish  or  bluish  bleb,  which  soon  breaks 
and  dries  up,  forming  a  scab.  The  skin  in  the  neighbourhood  of  the 
scab  then  usually  becomes  swollen,  and  sometimes  more  blebs  form. 
The  primary  nodule  at  the  point  of  infection  varies  from  the  size  of  a 
pea  to  that  of  a  nut.  Ordinarily  the  induration  and  oedematous  swell- 
ing extend  very  rapidly  in  all  directions  from  the  primary  nodule,  and 


§  77.]  SPLENIC  FEVER  OR  ANTHRAX.  395 

the  adjoining  lymphatic  glands  become  enlarged.  After  the  local 
symptoms  have  continued  some  forty-eight  to  sixty  hours  the  constitu- 
tional manifestations'  of  the  disease  begin  (high  fever,  great  weakness, 
delirium,  diarrhoea,  severe  vague  pains,  etc.).  If  there  is  a  fatal  termi- 
nation, death  occurs  very  often  with  symptoms  of  collapse,  generally 
after  the  disease  has  lasted  five  to  eight  days.  If  there  is  a  favourable 
termination  the  scab  is  sometimes  cast  off  by  a  process  of  suppuration. 
In  other  cases  there  is  observed  a  diffuse,  erysipelatous  form  of  car- 
buncle (Yirchow,  Bollinger) — for  example,  after  infection  by  a  fly-bite, 
and  also  when  the  infection  has  taken  place  internally.  The  course 
of  anthrax  when  the  infection  has  taken  place  from  the  intestine  is 
characterised  by  the  suddenness  of  the  onset  and  its  rapid  progress, 
with  vomiting,  diarrhoea,  cyanosis,  and  subsequent  collapse.  When 
the  infection  takes  place  through  the  lungs,  as  in  the  above-mentioned 
rag-sorters'  disease,  there  is  observed  a  pneumonia,  with  typhoid  or 
septic  symptoms,  and  for  the  most  part  a  rapidly  fatal  course.  The 
autopsy  in  man  reveals  essentially  the  same  changes  as  in  animals. 
There  are  immense  numbers  of  anthrax  bacilli  in  the  blood-vessels, 
and  particularly  in  the  capillaries  (Fig.  327). 

The  Diagnosis  of  Anthrax,  when  infection  has  occurred  through  the  skin, 
is  made  chiefly  from  the  characteristic  appearance  of  the  malignant  pustule, 
and  from  the  patient's  statements  concerning  his  occupation,  the  origin  of 
the  pustule,  etc.  If  necessary,  the  diagnosis  can  be  cleared  up  by  micro- 
scopical examination  of  the  carbuncle.  For  making  the  diagnosis  when  the 
infection  takes  place  from  within,  we  must  refer  the  reader  to  the  text-books 
on  internal  medicine. 

Prognosis. — The  prognosis  of  anthrax  in  man,  when  infection  takes  place 
externally,  depends  mainly  upon  whether  energetic  surgical  treatment  is 
undertaken  early  enough.  Lengyel  and  Koranyi,  by  adopting  suitable  local 
treatment,  lost  only  thirteen  out  of  one  hundred  and  forty-two  cases  of 
anthrax.  Patients  with  anthrax  resulting  from  internal  infection  (intestinal, 
pulmonary)  very  rarely  recover. 

The  Treatment  of  Anthrax. — In  the  treatment  of  anthrax  in  man 
the  fact  that  the  disease  remains  local  a  longer  time  than  in  animals  is 
of  the  greatest  importance.  If  the  patient  comes  under  observation 
early  enough,  it  is  our  duty  to  destroy  the  point  of  infection  as  rapidly 
and  thoroughly  as  possible — for  instance,  by  extirpation,  by  making 
an  eschar  with  the  Paquelin,  by  cauterisation  with  nitric  acid,  etc. 
Aqcording  to  Koch,  bichloride  of  mercury  is  the  most  effective  poison 
for  anthrax  bacilli,  l)eing  capable  of  killing  them  when  used  as  dilute 
as  1  part  to  300,000  of  water.  Consequently  it  is  an  excellent  plan  to 
use  in  and  around  the  point  of  infection  injections  of  one  tenth  per 
cent,  bichloride,  or  two  to  five  per  cent,  carbolic  acid  (Raimbert  and 


396  INFLAMMATION  AND  INJURIES. 

others),  or  dilute  tincture  of  iodine  (one  to  two  of  water,  Davaine). 
Russian  surgeons  in  particular  have  obtained  very  good  results  from 
the  free  use  of  carbolic  acid  both  subcutaneously  and  internally.  As 
much  as  half  a  grannne  of  carbolic  is  given  internally  during  the  day, 
and  a  considerable  quantity  is  injected  into  the  pustule.  In  suitable 
cases,  which  come  under  treatment  at  an  early  stage,  with  anthrax  in- 
fection located  in  an  extremity,  the  latter  can  be  tied  off  by  an  elastic 
tourniquet  (Nissen).  The  diet  should  be  strengthening  and  alcohol  is 
given  in  large  doses.  The  future  must  decide  whether  it  is  possible 
in  man,  as  in  animals,  to  prevent  anthrax  or  to  cure  it,  by  the  inoc- 
ulation of  other  kinds  of  bacteria  (see  page  391).  Emmerich  has  pre- 
pared a  germ-free  serum  from  the  blood  of  sheep  infected  with  ery- 
sipelas streptococci  and  used  it  in  human  anthrax.  The  reports  thus 
far  published  in  literature  are  too  few  to  allow  of  a  correct  judgment 
of  the  value  of  this  curative  serum. 

Symptomatic  Anthrax.— Symptomatic  anthrax  {charbon  symptomatique 
of  the  French)  is  a  disease  similar  to  anthrax,  afPecting  cattle,  which  occurs 
endemically  and  mostly  during  the  warm  months  of  the  year  in  many  re- 
gions, notably  the  Bavarian  Alps,  Baden,  Schleswig-Holstein.  etc.,  and  has 
long  been  confused  with  anthrax.  Symptomatic  anthrax  has  not  hitherto 
been  known  to  occur  in  man.  The  disease  has  been  studied  by  BolHnger, 
Kitasato,  and  others.     It  is  characterised  by  the  formation  of  irregularly 

outlined,  emphysematous,  ci'ackling 
^        «  ♦       swellings  of  the  skin  and  muscular 

^^»|V    ^  *  ^       tissue,  particularly  on  the  thigh,  and 

•      I  •»    *I^  A        by  a  peculiar  reddish-black  discolor- 

ation of  the  diseased  muscles.    In  the 
bloody  serous  fluid  at  the  focus  of  the 
disease  there  is  found  a  characteristic 
«  ^1^  J         ©  bacillus,  which  Kitasato  was  the  first 

^^0  •         ^.  to   obtain   in   pure  cultures  upon  a 

^f^  J     •    I        .  ^      ^^    •    ^M     solid  nutritive  medium.     By  inocu- 
^^  ^^     ^#  ^         '  lating  animals  with  this  bacillus  Kita- 

J^  *         sato  excited  typical  symptomatic  an- 

■%  ^  O  ^0  ^  thrax. 

Fig.    S28.  — Bacilli   of  symptomatic  anthrax.  The  6aCi7Zz<S  of  symptomatic  an- 

Spore- bearing  rods  from  a  culture  in  agar.      thrax  (Fig.  328)  is  a  rather  large,  slim, 
Cover-sjlass  preparation,  stained  with  fuch-  ,•      -,  ■  ,         -ji         i    ■    t 

sin.     x^  1000  (Friinkel  and  Pfeitferj.  actively    movmg    rod    with    plainly 

rounded  ends,  generally  occurring 
singly,  occasionally  in  pairs,  but  never  in  long  filaments.  It  is  strictly  anaero- 
bic, and  when  brought  in  contact  with  the  oxygen  of  the  air  soon  perishes. 
It  grows  at  ordinary  temperatures  above  18°  C,  but  best  in  the  incubator. 
The  spores  form  large,  strongly  refracting  bodies,  rather  long,  and  are  placed 
eccentrically  at  the  end  of  the  rod  (Fig.  328).  When  the  spores  become  free 
the  rest  of  the  bacillus  speedily  dies.  The  spores,  which  have  great  powers 
of  resistance,  do  not  form  in  living  animals,  but  do  so  in  dead  bodies  and  in 


^^  •  %.  41, 


78.] 


GLANDERS   OR   FARCY. 


397 


artificial  cultures.  It  is  worth  noting  that  the  older  cells, 
have  grown  in  media  unsuitable  for  them,  have  a  tendency 
lution  forms,  which  sometimes  take  the  shape  of  large, 
plump,  spindle-like  segments  enlarged  in  the  centre,  and 
revealing  a  granular  cloudiness  and  an  iri'egular  contour. 

In  gelatine  to  which  has  been  added  grape  sugar  or 
some  other  reducing  substance  there  develop  within  a  few 
days  spherical  masses,  which  rapidly  liquefy  the  nutritive 
medium  (Fig.  329j.  In  stab  cultures,  made  in  a  large  amount 
of  gelatine,  a  cloudy,  grey  liquefaction  takes  place  in  the 
most  deeply  placed  parts,  with  the  evolution  of  gas  having 
a  characteristic  acid  odour.  Agar,  at  the  temperature  of 
the  incubator,  becomes  filled  with  bubbles  of  gas  even  after 
the  lapse  of  twenty-four  hours.  In  bouillon,  white  flakes 
develop  at  the  bottom  of  the  vessel,  accompanied  by  the  for- 
mation of  gas.  When  cultivated  at  a  temperature  of  42°  to 
43°  C.  the  virulence  of  the  bacilli  is  rapidly  caused  to  disap- 
pear. The  spores,  particularly  when  subjected  to  high  tem- 
peratures, lose  their  virulence  ;  but  if  placed  in  a  twenty-per- 
cent, solution  of  lactic  acid  and  then  injected  into  susceptible 
animals,  they  can  be  made  to  regain  their  virulence,  and 
that,  too,  in  an  increased  amount.  By  inoculating  suscep- 
tible animals  with  pure  cultures  the  animals  quickly  die  of 
symptomatic  anthrax  with  the  above-described  symptoms. 
Under  natural  conditions  the  disease  occurs,  in  the  majority 
of  cases,  from  infection  of  small  wounds,  particularly  of 
the  extremities,  less  often  from  infection  through  the  lungs 
or  intestine.  The  poison  is  conveyed  especially  by  the 
spores,  as  the  bacilli  quickly  perish  when  exposed  to  the  air. 
It  is  possible  in  various  ways  to  obtain  immunity  from 
symptomatic  anthrax,  and  for  this  purpose  "vaccination'" 
with  suitable  "  vaccine  "  is  very  worthy  of  recommendation. 

The  bacilli  of  symptomatic  anthrax  are  stained  in  the 
ordinary  way.  The  little  rods,  when  subjected  to  Gram's 
method,  lose  their  stain  again.  The  spores  cannot  be  stained 
by  aqueous  solutions  of  the  aniline  dyes,  but  readily  take 
the  double  stain. 


or  those  which 
to  develop  invo- 


FiG.  329.— Bacilli 
of  symptomatic 
authrax.  Pure 
culture  four 
clays  old,  after 
scattering  the 
inoculating  ma- 
terial about 
in  grape-sugar 
gelatine  ;  un- 
stained ;  natu- 
ral size  (^Frank- 
el  and  Pfeitfer). 


§  78.  Glanders  or  Farcy  (Malleus). — Glanders  is  an  infectious  dis- 
ease due  to  iDacilli,  primarily  occurring,  by  preference,  iu  horses  and 
asses,  and  is  transmissible  to  man  and  all  domestic  animals,  with  the 
single  exception  of  cattle.  The  disease  is  characterised  by  the  pres- 
ence of  peculiar  small  and  large  nodules,  particularly  in  the  mucous 
membrane  of  the  respiratory  tract,  and  in  the  skin,  with  secondary 
metastatic  nodules  in  the  internal  organs  (spleen,  liver,  kidneys,  testicle, 
bones,  etc.). 

Loffler  and  Schlitz  demonstrated  four  years  ago  the  presence  of  the 
characteristic  bacilli  in  the  glanders  nodules  and  made  pure  cultures 


398 


INFLAMMATION  AND  INJURIES. 


of  the  bacilli  upon  artificial  nutritive  media,  and  produced  typical 
glanders  by  inoculating  various  animals  with  these  cultures.  Israel, 
Kitt,  and  Weichselbaum  have  also  found  the  same  bacilli  in  glanders, 
and  have  successfully  inoculated  other  animals  with  them,  so  that  there 
can  be  no  doubt  that  these  bacilli  are  the  cause  of  the  disease. 

Glanders  Bacilli. — The  glanders  bacilli  (Fig.  330)  are  slim  rods  similar 
to  tubercle  bacilli,  but  more  regular  as  regards  their  size,  and  somewhat  broader 
than  the  latter.  They  possess  no  inherent  power  of  motion.  The  bacilli,  like 
most  of  the  pathogenic  bacteria,  are  facultative  anaerobic,  and  can  be  culti- 
vated in  the  necessary  nutritive  medium  at  temperatures  ranging  between  25° 
and  40°  C,  and  in  the  presence  of  oxygen.  Upon  potatoes  there  forms,  at  the 
ordinary  incubator  temperature,  in  the  course  of  about  two  days,  a  yellowish, 
honey-like  layer,  which  afterwards  gradually  becomes  darker,  varying  from 
brownish  to  dark  red.  Upon  agar  the  colonies  form  a  whitish  shining  layer, 
and  upon  blood  serum,  which  does  not  become  liquefied,  a  clear,  transparent 
covering  in  the  form  of  drops,  which  later  coalesce.  The  formation  of  spores 
by  the  glanders  bacillus  has  not  yet  been  demonstrated,  but  is  considered 
probable  by  Loffler,  Baumgarten,  and  Rosenthal.  Prolonged  cultivation 
upon  artificial  nutritive  media  causes  the  glanders  bacillus  soon  to  lose  its 
virulence.  By  inoculation  of  pure  cultures  of  glanders  bacilli  upon  suscep- 
tible animals  (horse,  ass,  goat,  cat,  field  mouse,  house  mouse,  guinea-pig)  the 
typical  form  of  glanders  is  produced,  the  glanders  bacilli  being  mainly  found 


FiG.  330.— Bacillus  of  glanders.  Pure  cul- 
tures upon  glycerine-agar ;  teased  speci- 
men stained  with  carbolic  fuchsiu.  x  100 
(Frankel  and  Pfeiflfer). 


Fig.  331. — Glanders  bacilli.  Smear  of  pus 
from  a  guiuea-pig  that  had  died  of  glan- 
ders. The  four  crossed  bacilli  within  the 
group  of  leucocytes  are  particularly  char- 
acteristic.    X  650  (Heim). 


in  the  centime  of  the  specific  glanders  nodules.  Less  susceptibility  to  glanders 
is  evinced  by  hogs,  sheep,  rabbits,  and  dogs,  with  the  exception  of  young  dogs, 
which  according  to  Fliigge  are  very  susceptible  to  the  disease.  Cattle,  house 
mice,  white  mice,  and  rats,  are  entirely  unsusceptible.  Field  mice  die  in  from 
three  to  four  days  after  an  artificial  subcutaneous  infection  with  glanders ; 
guinea-pigs  only  in  the  course  of  several  weeks.  Leo  states  that  white  mice 
lose  their  natural  immunity  and  become  susceptible  to  glanders  if  they  are 
made  artificially  diabetic  by  feeding  them  with  phlorizin.  The  richer  the 
blood  of  a  particular  animal  in  oxygen,  the  less  able  is  the  glanders  poison. 


§  78.]  GLANDERS   OR  FARCY.  S99 

to  develop  (Sanarelli).  By  continuous  transmission  of  glanders  bacilli  from 
one  animal  to  another  it  is  possible  to  cause  a  remarkable  increase  in  their 
virulence  (Gamaleia).  Babes  obtained  the  chemical  product  of  metabolism 
of  the  glanders  bacilli  through  pi'ecipitation  from  filtered  cultures  in  horse- 
flesh bouillon,  by  equal  parts  of  ether  and  alcohol.  This  substance,  called 
"mallein"  or  "  morvin,"  does  not  cause 
local  lesions,  but  produces  symptoms  of 
intoxication  (fever,  convulsions,  nephritis, 
marasmus,  death).  Babes  cured  a  horse 
that  had  glanders  with  injections  of  mor- 
vin, and  he  also  used  protective  inocula- 
tions with  success. 

The  bacilli  exist  in  the  specific  new 
tissue  formations  partly  singly  and  partly 
in  irregular  collections  or  bunches  of  sev- 
eral parallel  rods.     The  glanders  prepara- 

A-  J.^         J.1  T       1  -u      -IT  Fig.  332. — Potato  culture  of  the  glanders- 

tions,  or  rather  the  glanders  bacilli,  are  bacillus  at  87'  C;  four  days  old. 

stained  with  concentrated  alkaline  solu- 
tions of  methyl  blue.  They  are  then  treated  with  greatly  diluted  acetic  acid, 
washed  in  alcohol,  and  embedded  in  oil  of  cedar.  Glanders  bacilli  cannot 
be  stained  by  Gram's  method.  Among  the  recent  methods  of  staining  the 
following  are  particularly  good :  Weigert's  aniline  method,  Unna's  dry 
method,  and  the  method  of  R.  Klihne  (sections  placed  for  six  to  eight  hours 
in  carbolised  methylene  blue,  then  decolorised  in  acetic  acid,  and  again  in 
distilled  water,  dried  upon  the  slide,  clarified  with  xylol  and  embedded  in 
Canada  balsam). 

Noniewicz  recommends  the  following  combination  of  LofQer's  and  Unna's 
staining  methods :  1.  Place  the  section  taken  from  alcohol  in  LoflB.er's  solu- 
tion of  methylene  blue  for  from  two  to  five  minutes.  2.  Wash  in  distilled 
water,  and  stain  for  from  two  to  five  seconds  in  seventy-five  parts  of  one- 
half-per-cent.  acetic  acid  and  twenty-five  parts  of  one-half-per-cent.  tropaeolin. 
3.  Wash  in  distilled  water.  4.  Dry  upon  the  slide,  apply  a  drop  of  xylol,  and 
examine  in  xylol  and  Canada  balsam. 

According  to  Noniewicz,  glanders  is  caused  partly  by  bacilli  and  partly 
by  a  coccus  form.  The  round  bodies  are  found  particularly  in  subacute  and 
chronic  glanders. 

Glanders  infection,  under  natural  conditions,  generally  occurs  through 
some  small  injury  of  the  skin  or  mucous  membranes,  and  by  inhalation. 
Babes  has  produced  glanders  in  guinea-pigs  by  rubbing  very  virulent  glan- 
ders bacilli  into  the  sound  skin ;  whence  it  follows  that  glanders  bacilli  are 
also  able  to  penetrate  into  the  hair  follicles  of  the  uninjured  skin. 

Glanders  in  Animals. — Glanders  occurs  in  horses  and  other  animals  in 
the  form  of  small  or  large  nodules,  or  as  a  diffuse  infiltration.  The  glanders 
nodules  appear  especially  upon  the  mucous  membrane  of  the  respiratory 
tract  and  upon  the  skin.  The  nodules  occurring  in  the  mucous  membrane 
of  the  respiratory  tract,  especially  that  of  the  nose,  the  larynx,  and  trachea, 
vary  between  the  size  of  a  grain  of  sand  and  a  pea.  At  the  outset  they  have 
a  greyish-white  or  greyish-yellow  colour,  and  appear  singly  or  in  groups 
and  are  surrounded  by  a  red  areola.     From  a  suppurative  breaking  down, 


400 


INFLAMMATION  AND  INJURIES. 


often  within  a  few  days,  there  result  proportionately  large  ulcers,  which 
usually  enlarge  rapidly  by  necrosis  of  the  surrounding  parts,  extending 
also  deeply  into  the  subjacent  tissues.  In  the  lungs  the  glanders  nodules 
ai'e  similar  to  tubercular  nodules,  appearing  partly  as  lobular  foci  of  inflam- 
mation and  partly  as  interstitial  nodules.  The  pulmonary  glanders  nodules 
occur,  according  to  Bollinger  and  otliers,  partly  from  direct  aspiration  of 
the  glanders  poison  and  partly  as  a  result  of  embolism.  In  addition  to 
the  circumscribed  glanders  nodules  there  are  also  found  in  the  lungs  diffuse 
infiltrations. 

Upon  the  skin  there  occur,  in  the  cutaneous  form  of  glanders,  small 
(miliary)  or  large  nodules,  accompanied  by  a  rapid  suppurative  breaking 
down,  and  the  formation  of  ulcers  which  quickly  extend  and  also  lead  to 
inflammation  of  the  lymphatic  vessels  and  glands.  Cutaneous  glanders  in 
rare  cases  may  also  occur,  by  an  embolic  process,  secondarih'  to  primary 
glanders  of  the  respiratory  mucous  membrane.  As  was  mentioned  before, 
secondary  glanders  may  also  be  found  in  the  spleen  and  liver  and  in  the 
bones,  less  often  in  the  kidneys  and  testes,  as  a  result  of  embolism. 

The  course  of  glanders  may  be  acute  or  chronic,  in  the  former  terminat- 
ing in  death  in  six  to  twelve  days ;  the  latter,  the  more  common  form,  may 
last  for  years. 

Glanders  in  Man. — The  transmission  of  glanders  to  man  does  not 
take  place  very  frequently.  Individuals — such  as  butchers,  hostlers, 
cavalry  soldiers,  veterinary  surgeons,  etc. — who  come  in  contact  with 

animals,  especially  horses,  which  have 
glanders,  are  particularly  apt  to  con- 
tract the  disease.  In  man  the  disease 
takes  the  form  of  glanders  of  the  con- 
junctiva, less  often  of  the  nasal  mu- 
cous membrane,  and  particularly  glan- 
ders of  the  skin,  originating  in  some 
insignificant  injury,  especially  about 
the  face  and  on  the  hands.  In  man 
also,  as  in  animals,  glanders  may  run 
an  acute  or  clironic  course,  and  there 
may  develop  the  above-described  glan- 
ders nodules  and  ulcerations  at  the 
point  of  infection,  and  secondary  nod- 
ules in  the  internal  organs  as  a  result  of  embolism.  Acute  glanders 
runs  a  course  marked  by  severe  typhoid,  septic  manifestations,  and 
sometimes  it  may  resemble  acute  articular  rheumatism.  The  disease 
not  infrequently  begins  with  a  general  feeling  of  malaise,  and  pains  in 
all  the  limbs,  in  the  joints  and  in  the  back.  In  conjunction  with  a 
high  fever  there  develop  at  the  point  of  infection  typical  glanders 
nodes  which  break  down  and  ulcerate.     Upon  the  skin  pustular  erup- 


T"iG.  333. — Acute  glanders  eisrht  days  old 
in  man.  VV ell-developed  ulcerations  of 
the  skin  of  the  face  (Birch-Hirschfeld). 


§  78.]  GLANDERS  OR  FARCY.  401 

tions  appear,  which  change  into  phagedsenic  ulcers,  having  a  dirty, 
lardaceous  base.  Birch- Hirschf  eld  saw  pemphigus-like  blebs  upon  the 
skin  of  the  nose  and  cheeks,  with  rapid  destruction  of  the  greater  part 
of  the  skin  of  the  face  (Fig.  333).  In  cutaneous  glanders  there  are  also 
not  infrequently  observed  diifuse  erysipelatous  inflammations,  and  par- 
ticularly lymphangitis  and  phlegmonous  infiltrations  of  the  subcuta- 
neous cellular  tissue,  terminating  in  suppuration  or  ulcerative  destruc- 
tive processes.  The  secondary  foci  of  glanders,  particularly  those  in  the 
internal  organs,  bear  in  acute  glanders  a  close  resemblance  in  every 
respect  to  pysemic  foci  of  pus,  in  chronic  glanders  to  cheesy  formations. 
The  above-described  affection  of  the  nose  so  characteristic  of  glan- 
ders in  the  horse,  is  not  so  frequently  observed  in  man,  and  occasion- 
ally it  first  makes  its  appearance  rather  late  in  the  disease.  Acute 
glanders  is  accompanied  by  high  fever,  and  runs  a  regularly  fatal 
course  within  days  or  weeks,  in  consequence  of  the  increasing  systemic 
infection,  with  the  formation  of  secondary  nodes  or  abscesses  in  the 
internal  organs  as  well  as  in  the  muscles  and  subcutaneous  cellular  tis- 
sue. Chronic  glanders  in  man  has  hitherto  been  less  accurately  ob- 
served. Konig  gives  its  average  duration  as  four  months.  It  runs 
a  course  essentially  analogous  to  the  above-described  chronic  glanders 
in  the  horse.  Birch-Hirschfeld  calls  attention  to  the  resemblance  of 
chronic  glanders  to  syphilitic  and  tubercular  disease.  According  to 
Konig,  the  mortality  of  chronic  glanders  is  about  fifty  per  cent. 

Diagnosis  of  Glanders. — The  diagnosis  of  glanders  in  primary  infection 
of  the  skin  and  nasal  mucous  membrane  is  usually  not  difficult,  in  conse- 
quence of  the  characteristic  behaviour  of  the  glanders  nodes  taken  in  con- 
junction with  the  occupation  of  the  patient.  Internal  glanders  of  the  larynx, 
trachea,  and  lungs  may  often  be  first  recognised  when  secondary  affections 
of  the  skin  occur,  or  when  the  characteristic  glanders  bacilli  are  demon- 
strated in  the  sputum.  The  demonstration  of  the  bacilli  in  every  case  is, 
of  course,  of  the  greatest  diagnostic  importance.  A  good  method  for  quickly 
diagnosing  glanders  consists  in  mixing  the  suspected  secretion  with  water 
and  then  injecting  it  intraperitoneally  into  male  guinea-pigs.  If  it  is  really 
glanders,  after  the  lapse  of  two  to  three  days  there  occurs  a  swelling  of  the 
testicles  which  increases  during  the  next  few  days.  Suppuration  occurs  within 
the  tunica  vaginalis  and  spreads  to  the  testicles ;  the  pus  contains  glanders 
bacilli.  Levy  and  Steinmetz  recommend  making  the  injection  in  the  median 
line  of  the  abdomen  above  the  bladder,  in  order  to  prevent  injury  to  the 
seminal  vesicles,  which  in  case  of  infection  might  give  rise  to  secondary 
inflammation  of  the  testicle.  It  is  particularly  important  in  glanders,  both 
for  the  patient  and  those  about  him,  to  make  an  early  diagnosis  of  the  dis- 
ease and  to  employ  energetic  treatment. 

Treatment  of  Glanders. — The  treatment  of  glanders  can  only  be  suc- 
cessful when  the  point  of  infection  can  be  destroyed  at  a  very  early 
28 


402  INFLAMMATION   AND    INJURIES. 

period  by  surgical  means — either  bj  extirpation,  by  the  Paquelin  or 
galvano-cautery,  or  by  strong  caustics  (nitric  acid,  chloride  of  zinc),  etc. 
The  remainder  of  the  treatment  is  symptomatic,  and  consists  mainly  in 
an  energetic  local  treatment  of  the  glanders  focus  by  incision.  Inunc- 
tions of  mercurial  ointment  (^two  to  three  grammes  a  day)  have  been 
repeatedly  used  with  success.  Iodine  and  arsenic  have  been  recom- 
mended internally.  Babes  has  obtained  cures  in  animals  by  using 
his  mallein  (page  399),  and  has  employed  protective  inoculations 
with  success. 

§  79.  Foot-and-Mouth  Disease  {Ajyht/ue  EplzooticcB). — The  foot-and- 
mouth  disease  is,  according  to  Bollinger,  an  acute  infectious  disease 
which  is  transmitted  exclusively  by  infection  from  one  animal  to  an- 
other. This  disease,  which  is  observed  particularly  in  cattle,  sheep, 
swine,  and  goats,  less  often  in  horses  and  dogs,  is  characterised  by 
moderate  febrile  constitutional  symptoms,  and  by  the  formation  of 
blebs  and  ulcers  upon  the  mucous  membrane  of  the  mouth  (stomatitis 
aphthosa),  in  the  clefts  of  the  hoofs,  and  on  the  udder.  For  the  poison 
to  enter  the  body,  an  injury,  according  to  Bollinger,  is  not  necessary ; 
it  clings  to  the  uninjured  epithelial  layer  of  the  cavity  of  the  mouth  or 
enters  the  system  through  the  lungs,  and  probably  also  with  the  food. 
The  disease  is  very  contagious.  The  course  of  foot-and-mouth  disease 
is,  as  a  rule,  favourable,  its  duration,  according  to  Bollinger,  being 
usually  twelve  to  fourteen  days,  rarely  less.  It  generally  terminates 
in  recovery,  and  only  young  and  cachectic  old  animals  occasionally 
succumb  to  the  disease  if  surrounded  by  unfavourable  conditions. 

The  cause  of  the  disease  is,  according  to  Stutzer  and  Hartleb,  a  pleomor- 
phous  mici'O-organism  which  is  very  pathogenic  for  mice  and  rabbits.  It 
appears  sometimes  as  an  oval  rod  of  variable  length  ;  tinder  special  condi- 
tions cocci,  diplococci,  and  streptococci  ai-e  formed,  which  are  always  embed- 
ded in  a  mucous  envelope.  Yeast-like  bodies  are  sometimes  ]3resent,  or  the 
bacterium  changes  into  a  streptothrix,  and  this  into  a  thread.  These  meta- 
morphoses can  be  studied  by  using  ciilture  media  of  different  composition. 
The  above  interesting  observations  made  by  Stutzer  and  Hartleb  need  further 
confirmation. 

Foot-and-mouth  disease  can  be  transmitted  to  man,  but  the  predis- 
position of  the  latter  to  the  disease  is  only  slight. 

Occnrrence  of  the  Foot-and-Mouth  Disease  in  Man. — The  transmission 
of  the  disease  to  man  occurs,  according  to  Bollinger,  most  frequently 
by  drinking  the  uncooked  milk  of  diseased  cows  (Hertwig,  Jacob),  or 
by  infection  of  a  wound,  particularly  on  the  hands  of  butchers,  or  as  a 
result  of  milking  cows  with  a  vesicular  eruption  on  their  udders,  or  by 
contact  with  the  saliva  of  animals  having  the  disease. 


§  80.]  HYDROPHOBIA.  403 

The  symptoms  of  the  disease  in  man — for  example,  after  infection 
through  milk — consist  in  an  ulcerative  stomatitis,  a  catarrhal  gastro- 
enteritis, accompanied  bj  fever,  and  frequently  in  a  vesicular  eruption 
upon  the  hands,  the  face,  and  other  portions  of  the  body.  If  the 
poison  is  transferred  through  a  wound — for  instance,  in  slaughtering 
or  milking  an  infected  animal — the  hand  and  forearm  become  swollen, 
vesicles  form,  and  the  patients  complain  at  the  same  time  of  pain  in 
the  mouth  and  dysphagia ;  and  later  vesicles  or  pustules  make  their 
appearance  on  other  portions  of  the  skin,  particularly  on  the  face.  The 
disease  lasts  five  to  eight  days ;  and  only  when  the  ulcers  in  the  mouth 
and  on  the  hands  take  on  a  virulent  character  and  heal  slowly  does  the 
affection  continue  for  two  to  four  weeks.  Secondary  phlegmonous- 
suppurative  inflammations  occasionally  make  their  appearance. 

In  a  great  majority  of  the  cases  the  disease  terminates  in  recovery, 
and  only  rarely,  particularly  in  weak  infants,  causes  death. 

Treatment. — The  treatment  is  essentially  dietetic.  Care  should  be 
taken  to  use  only  healthy  milk.  If  the  stomatitis  is  intense,  it  is  an 
excellent  plan  to  swab  the  mouth  out  repeatedly  with  a  borax  solution, 
and  to  employ  mild  cauterisation  of  the  erosions  and  ulcers  with  silver 
nitrate  in  the  form  of  a  stick.  The  vesicular  eruptions  on  the  skin 
should  be  treated  with  ungt.  lithargyr.  Hebrse,*  vaseline,  boro-glycerine 
ointment,  and  particularly  by  dusting  them  with  bismuth,  iodoform, 
or  oxide  of  zinc  with  starch  (one  to  five  to  ten). 

§  80.  Hydrophobia  {Lyssa,  rabies). — Hydrophobia  is  an  acute  infec- 
tious disease  which  occurs  chiefly  in  the  dog  and  related  species  of  animals 
— wolf,  fox,  jackal,  hyena.  It  consists  essentially  in  a  disease  of  the 
central  nervous  system,  and  is  characterised  by  a  long  and  extremely 
variable  period  of  incubation. 

Etiology  of  Rabies. — Rabies  originates  in  a  manner  similar  to  syphi- 
Hs — that  is,  by  direct  transference  of  the  poison  from  the  bearer  to  the 
receiver.  The  poison  only  takes  root  when  inoculated  into  an  injury 
of  the  skin  or  mucous  membranes. 

Rabies  is  almost  always  transmitted  through  the  bite  of  a  rabid  ani- 
mal, by  which  the  poison  is  directly  inoculated  into  the  wound.  The 
experiments  of  Roux  and  I^ocard  show  that  infection  may  even  re- 
sult from  a  dog  which  at  the  time  when  he  bites  or  licks  an  individ- 
ual is  entirely  healthy,  but  later  becomes  mad.  According  to  ISTovi, 
the  poison  of  rabies  may  also  be  transferred  to  animals  by  midges 
and  flies.  Decomposition  does  not  seem  to  destroy  its  virulence  very 
soon.     In  dead  animals  decomposing  in  the  air,  the  virulence,  accord- 

*  Unguentum  diachylon. 


404  INFLAMMATION  AND  INJURIES. 

ino;  to  Travali  and  Brancaleone,  could  not  be  found  after  twenty-one 
days.  In  buried  animals,  the  nervous  centres  were,  in  some  instances, 
found  virulent  even  after  the  lapse  of  forty-eight  days ;  in  other  cases 
everv  trace  of  virulence  had  disappeared  thirty-eight  days  after  burial. 
The  poison  of  rabies  is  destroyed  by  the  digestive  fluids.  Zagari  states 
that  the  virus  of  rabies  loses  its  virulence  very  quickly  when  in  con- 
tact with  oxygen  or  air,  as  it  also  does  in  a  dry  medium  and  wlicn 
the  temperature  is  somewhat  elevated  ;  but  in  a  space  devoid  of  air,  in 
carbonic  acid,  in  a  damp  medium,  and  at  low  temperatures,  it  remains 
active  for  a  long  time.  The  poison  of  rabies,  according  to  Pasteur,  is 
always  present  in  the  fresh  saliva,  the  blood,  the  spinal  cord,  and  in 
the  brain,  salivary  and  lachrymal  glands,  the  pancreas,  and  perhaps  the 
mammae  of  animals  affected  with  hydrophobia.  Bombicci  has  also  found 
that  the  suprarenal  capsules  are  always  virulent.  Di  Yestea,  Zagari, 
and  Schaffer  have  shown  that  the  rabies  poison  is  spread  throughout 
the  body  by  the  nerves,  in  addition  to  the  blood  and  lymphatic  vessels, 
and  this  nervous  distribution  of  the  poison  is  the  essential  factor  in  caus- 
ing the  diffuse  myelitis  of  the  central  nervous  system.  The  views  upon 
the  microbe  of  rabies  are  still  divided.  Gibier,  Brigidi,  and  Bianchi 
think  that  a  micrococcus  is  the  cause  of  hydrophobia,  while  Pasteur ' 
has  found  a  characteristic  bacillus  of  which  he  attempted  to  make  pure 
cultures,  and  which  for  a  long  time  he  considered  to  be  the  exciting 
cause  of  hydrophobia.  Bruschettini  has  recently  isolated  a  specific 
bacillus.  When  injected  under  the  dura  of  rabbits,  the  animals  died 
in  about  seventeen  days  after  symptoms  of  paralysis  had  appeared. 
As  yet  the  micro-organism  of  rabies  is  not  known  with  certainty. 

InocTilatioii  Experiments. — Raynaud,  Lannelougue,  Pasteur,  and  others 
have  transferred  the  disease  to  rabbits,  by  inoculating  them  with  the  saliva 
of  persons  affected  with  rabies.  Pasteur  obtained  from  the  blood  of  these 
rabbits  a  micro-organism  which  he  cultivated  in  veal  broth  ;  it  was  a  bacillus 
somewhat  contracted  in  the  centre,  and  surrounded  by  a  gelatinous  sub- 
stance. Pasteur  at  first  believed,  as  we  have  said,  that  he  had  found  in  this 
bacillus  the  excitant  of  rabies ;  but  he  then  produced  the  same  disease  by  in- 
oculating healthy  human  saliva,  and  he  found  the  same  micro-organisms  in 
the  inoculated  rabbits.  Vulpian  and  Frankel  obtained  the  same  results  by 
inoculating  rabbits  with  normal  saliva.  Brigidi  and  Bianchi  found  in  the 
saliva,  and  particularly  in  the  blood  of  three  individuals  with  rabies,  before 
and  after  death,  micrococci  occurring  singly  or  in  pairs  (diplococci).  Only 
one  of  the  attempts  at  inoculation  in  a  rabbit  was  successful.  Making  use  of 
Pasteur's  method,  brain  substance  was  used  for  inoculation  in  this  case.  A 
portion  of  the  brain  substance  taken  from  a  child  which  had  just  died  of 
rabies  was  placed  in  a  wound  in  a  rabbit's  brain  which  had  been  exposed 
through  a  small  opening  in  the  skull  and  dura.  The  wound  healed  without 
reaction  ;  the  rabies  began  after  the  lapse  of  thirty -two  days,  and  in  two  days 


§  80.]  HYDROPHOBIA.  405 

the  animal  was  dead.  The  autopsy  revealed  complete  cicatrisation  at  the 
point  of  operation,  intact  meninges,  intact  brain  and  spinal  cord,  and  no 
suppuration.  In  the  brain,  spinal  cord,  and  blood  numerous  micrococci  were 
found.  An  attempt  at  inoculation  with  the  brain  matter  of  this  animal 
gave  no  results. 

Contrary  to  the  views  hitherto  held  upon  the  subject,  L.  Gibier  has  suc- 
cessfully inoculated  birds  (chickens)  with  hydrophobia,  and  from  these  he 
again  transmitted  the  disease  to  rats  by  inoculation,  which  then  died  with  the 
characteristic  symptoms  of  rabies.  Sometimes  the  inoculated  birds  withstood 
the  disease.  Microscopical  examination  of  the  brain  of  the  diseased  animals 
always  revealed  the  presence  of  the  above-described  micrococcus  of  Gibier. 

Transmission  of  rabies  from  the  maternal  animal  to  the  foetus  in  utero 
has  been  observed  by  Perroncito  and  Carita  in  rabbits  and  guinea-pigs. 

Strengthening  and  Attenuation  of  the  Rabies  Poison  according  to  Pasteur. 
— It  is  well  known  that  Pasteur  has  artificially  strengthened  and  weakened 
the  virulence  of  the  poison  of  hydrophobia.  By  continued  transference  of 
the  poison  in  rabbits  Pasteur  obtained  a  very  pure  rabies  poison  which  is 
constant  in  its  effects.  The  fresh  spinal  cord  and  the  medullary  portion  of 
the  brain  of  such  animals  contain  the  strongest  virus.  If  portions  of  the 
spinal  cord  and  brain  are  dried,  the  virulence  gradually  diminishes  propor- 
tionately to  the  length  of  time  that  the  drying  is  continued.  Pasteur  has 
been  able,  by  means  of  systematic  inoculations  with  rabies  poison  of  increas- 
ing virulence,  to  make  dogs  immune  from  the  bite  of  mad  dogs  and  from  the 
artificially  transferred  rabies  poison  in  its  most  potent  form.  In  conjunction 
with  these  experiments  on  animals,  Pasteur  undertook,  for  therapeutic  pur- 
poses, protective  inoculation  in  individuals  who  had  been  bitten  by  dogs  pre- 
sumably mad  (see  pages  408-410,  Treatment  of  Rabies).  According  to  Tizzoni 
and  Schwarz,  the  immunising  substance,  as  in  tetanus  and  diphtheria,  is  only 
found  in  the  blood  serum  of  the  inoculated  animals  ;  it  behaves  like  globu- 
line,  and  probably  belongs  to  the  enzymes.  Therefore  they  recommend  that, 
as  in  tetanus  and  diphtheria,  the  blood  serum  of  animals  which  have  been 
rendered  immune  from  rabies  by  inoculation  should  also  be  employed  in 
man  for  prophylactic  and  curative  purposes. 

Action  of  the  Rabies  Poison. — The  action  of  the  still  unknown  rabies 
poison  is  probably  similar  to  that  of  the  tetanus  bacillus.  We  saw  in 
the  chapter  on  Tetanus,  wliicli  is  so  closely  related  to  rabies,  that  the 
number  of  the  bacilli  in  the  system  capable  of  demonstration  is  very 
small,  and  that  the  tetanus  bacilli  are  destructive  not  by  their  num- 
bers but  by  the  formation  of  the  poisonous  products  of  their  metab- 
olism (toxines).     The  poison  of  rabies  acts  similarly  to  strychnine. 

Rabies  in  the  Dog. — The  symptomatology  of  rabies  in  the  dog  is  briefly  as 
follows  :  A  stage  of  incubation  precedes  the  disease,  and  lasts  generally  three 
to  five  weeks,  seldom  less  or  more.  The  longest  duration  of  the  incubation 
stage,  according  to  Bollinger,  is  eight  months.  During  the  incubation  the 
wound  from  the  bite  usually  heals  very  rapidly,  without  any  particular  in- 
flammatory manifestations.  In  dogs,  two  forms  of  rabies  are  distinguished  : 
the  raging  madness,  or  rabies,  and  the  still  rabies.     The  symptoms  of  rabies 


406  INFLAMMATION  AND  INJURIES. 

vary  in  other  respects,  according'  to  the  race,  sex,  the  state  of  nutrition,  etc., 
of  tlie  animal.  The  raging  madness  usually  begins  with  a  stage  of  melan- 
cholia, which  is  chai'acterised  by  great  irritability  of  the  animal,  a  peculiar 
restlessness,  loss  of  appetite,  dysphagia,  and  nausea.  The  dog  shows  a  re- 
markable preference  for  all  soi-ts  of  indigestible  things,  such  as  hair,  earth, 
straw,  dung,  etc.  The  danger  for  man  is  the  greatest  during  this  stage,  and 
is  so  much  the  more  so  since  the  first  manifestations  are  often  very  insignifi- 
cant. The  initial  stage,  according  to  Bollinger,  lasts  one  half  to  two  to  tlu*ee 
days ;  then  follows  the  stage  of  real  madness — the  irritation  or  maniacal 
stage — lasting  three  to  four  days.  The  characteristic  manifestations  of  this 
stage,  which  only  occur  in  paroxysms,  are  the  change  in  the  disposition,  the 
continued  loss  of  appetite,  a  peculiar  change  in  the  voice,  an  impulse  to  escape 
and  run  about,  disturbances  of  consciousness,  a  marked  passion  for  biting, 
and  a  rapidly  increasing  emaciation.  A  noticeable  aversion  to  water  is  lack- 
ing, accoi'ding  to  Bollinger,  and  only  in  exceptional  instances  does  spasm 
occur  in  the  muscles  of  deglutition.  In  the  last  or  paralytic  stage  there  is  a 
constantly  increasing  weakness.  The  entire  picture  presented  by  the  bris- 
tling animal  is  frightful  to  look  at.  The  voice  becomes  constantly  hoarser, 
the  dyspnoea  increases,  and  death  generally  occurs  on  the  third,  fifth,  or 
sixth  day,  occasionally  with  partial  or  general  convulsions.  The  termination, 
according  to  Bollinger,  is  always  fatal ;  recovery  has  not  yet  been  observed. 

The  quiet  or  melancholic  form  of  rabies,  which,  according  to  Bollinger, 
makes  up  about  fifteen  to  twenty  per  cent,  of  the  total  number  of  cases 
of  madness,  runs  a  more  rapid  course,  as  there  is  no  maniacal  stage.  In 
the  first  stage  the  manifestations  are  the  same  as  in  the  wild  variety ;  then 
there  soon  follows  a  paralysis  of  the  lower  jaw,  the  mouth  remains  wide 
open,  the  voice  becomes  hoarse,  disturbances  of  consciousness,  rapid  ema- 
ciation, and  paralysis  of  the  hind  quarters  follow,  with  death  in  two  to 
three  days. 

The  results  of  the  autopsy  reveal  little  which  is  positive.  The  most  im- 
portant changes,  according  to  Bollinger,  are  a  dark,  thick  condition  of  the 
blood,  cedema  of  the  brain,  more  or  less  pronounced  catarrhal  changes  in  all 
the  mucous  membranes,  particularly  in  the  respiratory  and  digestive  tracts, 
frequently  combined  with  hypera^raia  and  ecchymoses,  hyperaimia  and  cya- 
nosis of  the  parenchyma  of  various  organs,  and  a  high  grade  of  emaciation. 
In  the  stomach  and  intestine  there  are  usually  found,  instead  of  the  normal 
food  stuffs,  indigestible  foreign  bodies  of  various  kinds. 

Hydrophobia  in  Man. — In  man,  rabies  occurs  by  far  the  most  fre- 
quently as  the  result  of  the  bite  of  a  mad  dog  (ninety  per  cent.),  l6ss 
often  of  cats  (four  per  cent.),  wolves  (four  per  cent.),  and  foxes  (two 
per  cent.),  and  it  always  terminates  fatally.  Children,  especially,  often 
fall  victims  to  the  disease.  According  to  the  French  statistics,  one  third 
to  one  fourth  of  all  the  cases  of  the  disease  occur  in  children  under 
fifteen  years  of  age  (Ollivier),  The  question  as  to  how  many  of  those 
who  are  bitten  by  mad  dogs  are  attacked  afterwards  by  the  disease, 
has  received  very  diverse  answers.  Bollinger  is  right  in  maintaining 
that  the   percentage   of  those  attacked  by  the  disease  depends  upon 


§  80.]  HYDROPHOBIA.      .  407 

whether  one  on!  j  takes  into  account  the  bites  of  really  mad  animals,  or 
also  of  those  which  are  supposed  to  be  mad ;  and  finally  upon  whether, 
and  when,  energetic  prophylactic  treatment  of  the  wound  made  bj  the 
bite  is  adopted.  This  explains  the  discrepancies  in  the  records,  some 
of  which  state  that  a  half,  others  a  third,  or  even  not  more  than  five 
per  cent.,  of  those  who  are  bitten  become  affected  with  hydrophobia. 
The  cases  of  death  from  rabies  in  animals  and  in  man  have  diminished 
remarkably  in  states  such  as  Prussia,  where  there  are  stringent  laws 
levied  against  all  dogs  found  running  about  loose,  or  those  thought  to 
have  hydrophobia,  and  where  the  muzzling  of  dogs  is  compulsory ; 
indeed,  in  such  states,  as  Fliigge  has  stated,  rabies  in  man  has  as  good 
as  entirely  disappeared.  As  yet  no  undisputed  case  has  been  observed 
of  the  transmission  of  rabies  from  man  to  man. 

In  man,  also,  rabies  is  marked  by  a  stage  of  incubation,  generally 
of  eighteen  to  sixty  days,  and  occasionally  of  three  to  six  months.  An 
incubation  of  less  than  fourteen  days  is  rare,  and  only  in  exceptional 
instances  are  there  incubations  lasting  from  six  to  twelve  months. 
After  the  termination  of  the  incubation  period,  during  which  the  per- 
son who  has  been  bitten  feels  perfectly  well,  and  the  wound  has  healed, 
usually  with  exceptional  rapidity,  the  rabies  begins  with  psychical  dis- 
turbances (a  melancholic  frame  of  mind,  excitability,  restlessness,  loss 
of  sleep),  loss  of  appetite,  and  occasionally,  even  at  this  stage,  an 
antipathy  towards  liquids.  The  local  manifestations  at  the  point  of 
the  bite,  which  has  generally  healed,  are  not  constant;  occasionally 
there  is  observed  an  inflammatory  swelling  of  the  cicatrix,  or  the 
patient  complains  of  pain,  burning  or  itching.  Fever  is  usually  not 
present.  The  prodromal  stage  lasts,  for  the  most  part,  about  twenty- 
four  hours,  rarely  longer.  The  first  symptom  of  true  hydrophobia  in 
man  is  a  spasm  of  the  pharynx  resulting  in  an  inability  to  swallow. 
There  now  occur,  in  the  form  of  paroxysms,  severe  respiratory  and 
pharyngeal  spasms  caused  by  any  kind  of  irritation,  and  especially  by 
the  sight  of  liquids — hence  the  name  "  hydrophobia."  At  the  same 
time  there  are  observed  reflex  spasms,  for  the  most  part  general  clonic 
spasms,  less  often  tetanic.  There  is  also  a  characteristic  increased  reflex 
excitability  of  the  nerves  of  special  sense ;  the  patients  suffer  from  a 
perverted  sense  of  smell;  they  are  over-sensitive  to  any  noise,  any 
draught  of  air,  etc.  They  are  usually  afflicted  with  a  nameless  dread, 
which  does  not  allow  them  to  get  any  rest ;  the  salivary  secretion  is  in- 
creased ;  the  mind  remains,  in  the  intervals,  for  the  most  part  clear, 
but  from  time  to  time  there  are  maniacal  seizures,  partly  as  a  result  of 
the  terrible  dread  and  the  oppression  in  the  chest  due  to  the  feeling 
of  suffocation,  and  partly  as  a  result  of  the  attempts  of  others  to  re- 


408  INFLAMMATION   AND  INJURIES. 

strain  tliein.  The  pulse,  whicli  is  at  the  outset  full,  gradually  becomes 
weaker  and  more  frequent,  particularly  after  the  paroxysms,  when  it 
reaches  120  to  160  or  more.  The  temperature  is  generally  only 
slightly  elevated— 38°  to  38.5°  C.  (100.1:°  to  101.3°  F.)— seldom  reach- 
ino-  40°  C.  (101°  F.)  or  more.  After  the  above-described  manifesta- 
tions of  the  second  stage  have  lasted  for  one  to  two  to  three  days,  there 
occurs,  with  an  abatement  of  the  spasms  and  the  difficulty  in  breathing 
and  swallowing,  a  general  exhaustion ;  death  then  follows  within  the 
next  few  hours,  with  convulsions,  or  quietly,  or  less  often  during  a 
recurrence  of  one  of  the  attacks  of  spasm.  The  consciousness  is  usu- 
ally unclouded  up  to  the  last. 

The  duration  of  rabies  in  man  is,  in  the  majority  of  cases,  two  to 
four  days,  rarely  more  or  less ;  the  termination,  as  in  animals,  is  regu- 
larly fatal. 

Result  of  Autopsy. — The  results  of  the  autopsy  in  man  are  similar  to  what 
we  have  briefly  described  for  rabies  in  animals — that  is,  the  autopsy  shows 
practically  no  characteristic  changes.  Schaifer  called  attention  to  an  acute 
diffuse  myelitis  of  the  central  nervous  system  in  both  the  grey  and  the  white 
matter,  with  marked  degeneration  of  the  nerve  fibres  and  ganglia.  Popoff 
often  found  in  the  nerve  fibres  of  the  central  nervous  system  a  very  high 
grade  of  hypertrophy  of  the  axis  cylinder  and  an  atrophic  condition  of  the 
nerve  cells,  with  conspicuous  pigmentation.  Popoff  saw  these  changes 
chiefly  in  the  motor  centres.  At  all  events,  there  is  a  pronounced  parenchym- 
atous myelitis,  which  affects  principally  the  nuclei  of  the  motor  nerves 
(Charcot,  Leyden,  Erb). 

Diagnosis. — In  the  diagnosis  of  rabies  in  man,  the  pharyngeal  and  respir- 
atoi'y  spasms,  the  increased  reflex  excitability,  and  the  paroxysmal  natui'e  of 
the  manifestations  of  the  disease  are  characteristic.  Rabies  can  only  be  con- 
fused with  tetanus  of  the  head,  the  so-called  tetanus  hydropTiohicus,  which 
occurs  in  conjunction  with  wounds  in  the  region  supplied  by  the  cranial 
nerves  (§  73),  as  in  this  also  there  are  pharyngeal  spasms.  In  such  cases  the 
patient's  statements  may  point  to  the  correct  diagnosis.  Tetanus,  for  the 
most  part,  occurs  between  the  third  to  the  eighth  to  the  tenth  day  after  the 
injury,  and  hydrophobia  in  the  fourth  to  the  seventh  week  after  the  reception 
of  a  bite  fi'om  a  rabid  animal. 

Prognosis. — The  prognosis  of  rabies  in  man  is  regularly  fatal.  No  certain 
cases  of  recovery  fi^om  true  hydrophobia  have  been  ob-served. 

Treatment  of  Rabies  in  Man. — Prophylaxis  is  of  the  first  importance 
in  the  treatment.  Strictly  enforced  police  laws  against  allowing  dogs 
to  run  about  loose  without  their  masters,  also  a  high  dog-tax,  and  laws 
compelling  the  use  of  muzzles,  are  of  the  greatest  importance  in  less- 
ening the  occurrence  and  the  spread  of  hydrophobia.  As  we  men- 
tioned before,  it  has  been  possible  in  this  way  to  very  materially  dimin- 
ish the  frequency  of  the  disease. 


§  80.]  HYDROPHOBIA.  409 

If  a  person  is  bitten  by  a  mad  dog,  or  bj  one  supposed  to  be  mad, 
the  poison  at  the  point  of  infection — that  is,  in  the  wound — must  be 
destroyed  as  soon  and  as  energetically  as  possible  by  careful  disinfec- 
tion with  a  one-fifth-per-cent.  solution  of  bichloride  of  mercury  or  a 
five-per-cent.  solution  of  carbolic  acid,  followed  by  energetic  cauterisa- 
tion with  the  red-hot  iron,  the  Paquelin,  or  with  chemical  caustics 
(caustic  potash,  sulphuric  and  nitric  acids).  It  is  also  a  very  good 
plan  to  immediately  suck  out  the  fresh  wound.  Excision  of  the 
wound  or  cicatrix,  with  subsequent  cauterisation,  may  be  efficacious, 
even  though  done  several  days  or  weeks  after  the  injury  was  received. 

Pasteur's  Protective  Inoculation. — It  is  well  kno%vn  that  Pasteur  has 
undertaken  protective  inoculations  upon  people  who  have  been  bitten 
by  mad  dogs,  after  he  Jiad  made  the  discovery,  as  stated  above,  that 
dogs  become  gradually  unsusceptible  to  hydrophobia  when  inoculated 
with  rabies  poison  the  virulence  of  which  is  gradually  increased.  Bor- 
doni-Uffreduzzi  has  successfully  practised  Pasteur's  preventive  inocula- 
tion on  dogs  and  on  one  horse.  Tizzoni  and  Schwarz  recommend  the 
use  of  blood  serum  taken  from  animals  (rabbits,  dogs)  rendered  arti- 
ficially immune,  for  prophylactic  and  curative  purposes  in  man,  since 
the  immunising  or  curative  substance  is,  as  in  tetanus,  chiefly  found  in 
the  blood  serum. 

Technique  of  Pasteur's  Protective  Inoculation.— Pasteur's  manner  of  per- 
forming i^rotective  inoculation  is  as  follows  :  A  suitable  amount  of  the  dried 
spinal  cord  of  an  animal  which  has  had  rabies  is  pulverised  with  sterilised 
instruments,  and  to  it  is  added  sterilised  veal  bouillon.  Lymph  is  thus 
obtained  of  varying  virulence,  according  to  the  relative  amounts  of  the  con- 
stituents and  the  length  of  time  that  the  cord  lias  been  dried.  The  material 
for  inoculation  is  now  injected  with  a  hypodermic  needle  beneath  the  skin 
of  the  abdomen  a  little  below  the  ribs,  three  fourths  of  a  cubic  centimetre 
being  used  for  full-grown  men  and  a  little  less  for  women,  and  half  a  cubic 
centimetre  for  children.  Pasteur  usually  begins  with  a  spinal  cord  which 
has  been  dried  for  fourteen  days,  then  on  the  following  day  an  injection  is 
naade  of  one  dried  for  thirteen  days,  etc.,  until  for  the  tenth  inoculation  a 
spinal  cord  is  employed  which  has  only  been  dried  five  days ;  the  patients 
are  then  discharged.  Sometimes,  especially  in  bad  cases — for  example,  in 
Russians  bitten  by  mad  wolves — according  to  Uffelmann's  report,  inocula- 
tions are  made  two  to  three  times  a  day  with  rabies  poison  of  increasing 
virulence.  In  this  manner  Pasteur  has  inoculated  a  great  number  of  people 
who  had  presumably  been  bitten  by  mad  dogs ;  of  these  people  some  died  of 
rabies  a  short  time  after  the  treatment,  and  others  later,  and  it  is  not  impos- 
sible that  death  from  hydrophobia  may  have  occurred  in  some  of  the  cases 
in  consequence  of  the  inoculation.  But  in  a  number  of  cases  the  protective 
inoculation  has  given  the  wished-for  result.  At  all  events,  Pasteur's  experi- 
ments are  of  the  greatest  scientific  interest ;  but  we  must  acknowledge,  with 
Koch  and  Flligge,  that  Pasteur's  protective  inoculation  for  man  has  been 
29 


410  INFLAMxMATIOX  AND   INJURIES. 

used,  for  practical  purposes,  much  too  soon.  A  more  thorough  scientific 
investigation  of  the  method  should  have  been  made  before  it  was  put  to 
practical  use.  The  protective  inoculation  should  be  employed  with  great 
caution,  for  there  is  the  danger  that  persons  who  would  perhaps  have 
remained  well  without  inoculation  might  acquire  hydrophobia  in  conse- 
quence of  the  inoculation,  and  die. 

Bordoni-Uffreduzzi  has  likewise  employed  Pasteur's  method  of  treatment 
with  the  best  success,  and  in  his  statistics  during  the  years  1886-"88  he  re- 
ports :  Two  hundred  and  forty-one  persons  were  bitten  by  animals  which 
were  experimentally  proved  to  have  rabies  ;  in  the  case  of  two  hundred  and 
forty-five  more,  treated  by  Pasteur's  method,  the  hydrophobia  of  the  animals 
which  bit  them  was  rendered  certain  by  physicians'  certificates  or  by  clinical 
observation ;  in  forty-five  persons  the  diagnosis  of  rabies  was  doubtful. 
Only  six  of  the  first  group  died  ;  of  the  second,  four ;  of  the  third,  none  ;  and 
coTisequently  the  mortality  of  the  whole  list  was  1.88  per  cent. 

When  the  disease  has  once  Itroken  out,  usually  no  treatment  is 
of  avail.  We  are  then  forced  to  limit  ourselves  to  easing  the  great 
sufferings  of  the  patient  by  symptomatic  treatment.  First  of  all, 
and  as  soon  as  possible,  large  doses  of  curare  should  be  injected  sub- 
cutaneously. 

Pensoldt,  in  one  case  occurring  in  an  eleven-year-old  boy,  employed 
without  success  very  large  doses  of  curare,  injecting  on  an  average 
0.01  to  0.02  gi-amme  every  half  hour,  and  in  the  course  of  one  to  two 
and  a  half  hours  the  full  fatal  amount  of  curare  was  administered. 
Curare  is  very  valuable  in  all  cases  as  a  symptomatic  remedy  for 
modifying  the  pharyngeal  and  respiratory  spasms,  but  it  does  not  pos- 
"sess  an  actual  curative  effect  upon  the  disease.  Remedies  like  chloral 
and  chloroform  are  indispensable.  For  the  severe  convulsive  and 
maniacal  seizures  of  the  patient  the  continuous  administration  of  chlo- 
roform by  inhalation  is  probably  the  best  treatment. 

Recently  various  remedies  have  been  recommended  for  rabies.  For 
example,  Kartschewskji  speaks  well  of  the  internal  use  of  cantharides 
powder  (0.06  gramme  pro  die)  for  a  week,  and  at  the  same  time  the 
application  of  emplastrum  cantharidum  to  the  wound  made  by  the 
bite.  According  to  the  experiments  of  De  Blasi  and  Russo  Travali, 
the  poison  of  rabies  has  little  power  of  resistance  against  the  ordinary 
antiseptics  and  caustics,  and  they  recommend  creolin  and  lemon-juice. 
The  latter,  as  is  well  known,  has  a  great  reputation  as  a  popular 
remedy. 

§  81.  Poisoning  by  Insects,  Snakes,  Etc. — From  the  bites  of  certain 
insects  and  snakes,  poisoning,  sometimes  mild  and  sometimes  severe, 
may  result,  the  nature  of  which  we  do  not  as  yet  fully  understand. 
Among  the  injuries  caused  by  the  stings  of  insects  belong  the  bites  of 


§81.]  POISONING   BY  INSECTS,  SNAKES,  ETC.  411 

gnats,  fleas,  bugs,  etc.,  after  which,  as  a  result  of  the  introduction  of 
some  irritating  substance,  there  ensue  local  inflammatory  manifesta- 
tions in  the  form  of  redness  and  wheals,  with  itching  and  burning. 
Severer  inflammation  follows  the  wound  inflicted  by  the  sting  which  is 
situated  in  the  posterior  end  of  the  bodies  of  bees  and  wasps.  Their 
sting  involves  a  decided  poisoning  of  the  wound,  which  occasionally 
presents  itself  as  a  very  extensive,  painful  inflammation,  with  redness 
and  swelling,  and  not  rarely  there  may  even  be  alarming  constitutional 
symptoms.  Many  individuals  are  exceedingly  susceptible  to  the  stings 
of  bees  and  wasps.  The  local  inflammatory  manifestations  usually  sub- 
side very  soon.  The  constitutional  symptoms  which  now  and  then 
occur — for  instance,  after  the  direct  injury  of  a  small  cutaneous  vein 
or  a  lymphatic  vessel — consist  sometimes  in  a  peculiar  state  of  collapse  ; 
the  skin  is  cool,  and  covered  with  a  clammy  sweat,  the  pulse  is  small 
and  rapid,  and  occasionally  a  condition  of  coma  is  observed.  These 
threatening  constitutional  symptoms  last  usually  only  a  few  hours,  but 
the  patients  generally  feel  noticeably  feeble  for  several  days.  There 
are  also  many  examples  known  of  men  and  animals  dying  in  a  short 
time  after  being  attacked  by  a  swarm  of  bees  or  wasps.  The  nature  of 
the  wasp  and  bee  poison  is  as  yet  unknown. 

Injuries  from  Tarantulas  and  Scorpions. — I  should  also  mention  in- 
juries produced  by  the  tarantulas  and  scorpions  of  southern  countries, 
with  the  subsequent  extensive  local  inflammations,  which  never  termi- 
nate fatally. 

The  treai/ment  of  the  above-mentioned  injuries,  particularly  the 
stings  of  bees,  wasps,  tarantulas,  and  scorpions,  is  best  carried  out  with 
ammonia  and  antiphlogistic  remedies.  As  Billroth  says,  bee-tenders 
employ  scorpion  oil  as  a  kind  of  antidote  for  bee  stings — that  is,  olive 
oil  in  which  some  scorpions  have  been  kept. 

Injuries  from  Venomous  Snakes. — The  injuries  due  to  poisonous 
snakes  are  relatively  rare  in  our  zones  as  compared  with  the  tropics. 
The  nature  of  the  snake  poison  is  as  yet  unknown  to  us  ;  it  is  probably 
a  poisonous  alkaloid  which  is  contained  in  the  secretion  of  the  poison 
glands.  In  Europe  there  are  ordinarily  found  only  three  kinds  of 
poisonous  snakes :  the  vipera  berus,  the  vipera  redii,  and  the  vipera 
aspis.  These  poisonous  snakes  have  two  hook-shaped  poison  teeth,  in 
which  the  excretory  ducts  of  small  glands  empty.  At  the  time  of  the 
bite  the  glands  empty  their  poisonous  juices  into  the  wound.  By 
drying  the  secretion  from  the  poison  glands  of  forty  asps,  Karlinski 
obtained  fifteen  grammes  of  a  white  amorphous  mass,  easily  soluble 
in  water  and  alcohol,  a  twenty-per-cent.  aqueous  solution  of  which  cor- 
responded in  its  action  to  the  fresh  poison  coming  from  the  poison 


412  INFLAMMATION  AND   INJURIES. 

2;lands  of  the  adder.  According  to  Phisalix,  Bertrand,  and  Calmette, 
snake  poison  can  be  considerably  weakened  by  heating  it  to  70°-75°  C. 
and  by  certain  chemical  substances.  Various  snake  poisons,  including 
the  poison  of  the  cobra,  are  destroyed  by  permanganate  of  potash  and 
chlorine  compounds,  but  are  very  resistant  to  acids  and  most  of  the 
common  antiseptics  (bichloride,  nitrate  of  silver).  Calmette  states  that 
immunity  can  1)6  acquired  by  gradually  accustoming  the  body  to  the 
poison,  and  supplying  it  with  an  antitoxic  chemical  su1)stance  (chloride 
of  gold,  hypochloride  of  sodium).  The  serum  of  immunized  animals 
is  antitoxic  to  snake  poisons  of  diiierent  origins.  According  to  Phi- 
salix, a  poisonous  and  an  immunizing  substance  are  found  in  vipers' 
blood  simultaneously. 

The  manifestations  after  the  bite  of  these  poisonous  snakes  consist 
in  a  very  painful  local  inflammation,  in  coagulation  of  the  blood  in  the 
parts  immediately  adjoining  the  wound,  in  thrombosis  of  the  blood- 
vessels, not  infrequently  in  gangrene,  vomiting,  high  fever,  a  feeling 
of  anxiety,  cramps,  great  weakness,  etc.  The  affected  ^^ortion  of  the 
body  is  subsequently  often  remarkably  devoid  of  sensation.  Occasion- 
ally death  occurs  in  a  relatively  short  time,  preceded  by  an  increasing 
state  of  collapse.  The  autopsy  sometimes  shows  extensive  thrombosis, 
and  at  other  times  the  latter  are  absent.  If  a  person  bitten  by  a  viper 
redii  survives  the  first  two  days,  the  prognosis  is  in  general  favourable. 
Out  of  179  cases  of  bites  by  the  viper  redii  only  5  ended  fatally, 
with  symptoms  of  asphyxia,  intestinal  hsemorrhage,  cerebral  compres- 
sion, pulmonary  oedema,  and  cardiac  weakness.  Death  occurred  in 
these  cases  in  -4,  18,  and  60  hours  and  10  to  12  days. 

The  best  treatment  for  these  snake-bites  is  to  immediately  suck  the 
wound — a  procedure  entirely  free  from  danger — then  to  wash  out  the 
wound  with  bichloride  of  mercury,  carbolic  acid,  absolute  alcohol,  etc., 
and,  when  possible,  to  cauterise  the  wound  with  some  energetic  liquid 
caustic  or  with  the  hot  iron.  To  prevent  the  rapid  absorption  of  the 
poison,  it  is  a  very  good  plan  to  employ  the  popular  remedy  of  tying 
off  the  injured  portion  of  the  body — an  extremity,  for  instance — as 
soon  as  possible,  close  above  the  bite.  Energetic  antiphlogistic  meas- 
ures are  adopted  for  the  local  inflammation.  Finally,  the  internal  and 
subcutaneous  administration  of  liquor  ammonii  fortior  has  been  recom- 
mended, a  hypodermic  syringe  full  (one  part  liq.  amnion,  fort,  with 
one  to  two  to  three  parts  water)  being  used  as  a  subcutaneous  injec- 
tion ;  internally  ten  to  twelve  drops  of  the  same  mixture  should  be 
given  many  times  each  day.  Karlinski  praises  the  injection  of  one 
per  cent,  chromic  acid  and  of  chlorine  water  (Lenz')  into  the  wound 
made  by  the  bite  and  the  surrounding  parts.     Large  doses  of  alcohol 


§  82.]     THE  POISONING  OF  WOUNDS  BY  INDIAN  ARROW  POISON.       413 

(whiskey)  and  energetic  active  motion  of  the  muscles  are  in  great  re- 
pute among  the  laity. 

The  most  dangerous  poisonous  serpents  are  the  American  rattle- 
snake and  the  cobra  species  of  Asia  and  Africa.  After  injuries  in- 
flicted by  the  bite  of  these  snakes  there  ensue  extremely  severe  local 
inflammations  which  terminate  in  gangrene.  The  constitutional  mani- 
festations are  like  those  in  hydrocyanic-acid  poisoning,  consisting  in  a 
feeling  of  dread,  oppression  of  the  chest,  cyanosis,  delirium,  convul- 
sions, and  stupor.  Death  follows,  occasionally  in  a  few  hours,  with 
symptoms  of  collapse  ;  in  fact,  death  not  infrequently  occurs  before  any 
local  symptoms  make  their  appearance.  It  is  of  practical  importance 
to  note  that  the  poison  may  even  have  a  fatal  effect  when  in  a  dried 
condition  or  in  an  alcoholic  preparation.  According  to  Cohnheim, 
death  from  a  poisonous  snake-bite  is  in  all  probability  caused  essen- 
tially by  the  disintegration  of  the  red  blood-corpuscles. 

The  treatment  is  in  general  like  that  for  the  bite  of  a  vipera  berus. 
Richards  and  De  Lacerda,  basing  their  opinion  upon  experiments  with 
the  poison  of  the  cobra,  recommend  the  subcutaneous  injection  of  a 
five-per-cent.  aqueous  solution  of  permanganate  of  potassium  (eight 
to  twelve  grammes  of  the  solution).  Immediately  after  the  reception 
of  the  bite  a  ligature  should  be  placed  on  the  proximal  side  of  the 
wound,  the  ligature  not  being  removed  until  several  minutes  after  mak- 
ing the  injection.  In  one  case  potassium  permanganate  was  injected 
with  success  twenty-five  minutes  after  the  reception  of  the  bite.  The 
length  of  time  within  which  a  subcutaneous  injection  of  potassium 
permanganate  is  attended  with  success  becomes  proportionately  pro- 
longed when  a  ligature  is  applied  above  the  poisoned  wound.  If  the 
poison  has  already  caused  constitutional  symptoms,  Ilichards's  obser- 
vations show  that  the  injection  of  permanganate  of  potassium  has  no 
effect. 

§  82.  The  Poisoning  of  Wounds  by  Indian  Arrow  Poison. — This  is 
perhaps  the  best  place  briefly  to  consider  the  wound  infections  pro- 
duced, for  instance,  by  the  poisoned  points  of  arrows  used  by  the  Indians. 
According  to  "W".  T.  Parker,  the  arrow-points  of  the  American  Indians 
are  poisoned  with  a  devilish  cunning,  and  the  process  is  frequently 
kept  secret.  Vegetable  poisons,  especially  curare  or  urari,  or  decom- 
posing putrid  substances  (decomposing  meat  and  blood,  for  instance,  of 
dead  enemies,  decomposing  liver,  etc.),  or  snake  poisons,  made,  for  ex- 
ample, from  the  crushed  heads  of  serpents,  are  employed.  There  is 
also  a  partiality  for  using  the  liver  of  an  ox,  which  is  pierced  with 
arrows  and  allowed  to  decompose  in  the  sun ;  crushed  ants  are  also 
added  to  the  mixture.     The  symptoms  of  poisoning  differ  according 


414  IXFLAMMATIOX   AND   INJURIES. 

to  whether  a  vegetable  poison  like  curare,  or  putrid  substances,  or  ani- 
mal poisons  like  those  of  snakes,  or  mixed  poisons  are  employed.  The 
action  of  curare,  the  real  arrow  poison  of  the  Indians,  is,  a*  is  well 
known,  to  paralyse  voluntary  muscles,  except  those  of  the  heart  and 
respiration.  The  cardiac  and  respiratory  activity  only  succumb  after 
poisoning  with  very  large  doses  of  curare.  The  American  Indians 
still  commonly  use  the  arrow,  in  addition  to  firearms,  for  war  and  the 
chase.  The  point  of  the  war  arrow,  according  to  "W.  T.  Parker,  is 
short  and  broad,  and  so  formed  as  to  enter  easily  betweeu  the  ribs  of  a 
man.  The  huntmg  arrow  is  the  weapon  to  be  most  feared.  The  In- 
dians can  shoot  this  about  one  hundred  metres,  and  with  as  great 
accuracy  as  the  best  modern  rifle.  The  arrow  penetrates  the  tissues 
with  great  force,  and  can  jierforate  the  stoutest  Itones.  Gutters  are 
made  in  the  shaft  to  j)ermit  the  blood  to  escape  from  the  wound.  The 
point  of  the  arrow  is  fastened  to  the  shaft  in  such  a  manner  that  when 
it  becomes  wet.  and  consequently  when  it  is  in  a  wound,  or  when  at- 
tempts are  made  at  extraction,  it  easily  becomes  loosened  and  remains 
in  the  wound.  The  arrow-points  are  made  of  iron,  pebbles,  bones, 
glass,  wood,  etc.  The  Indians  are  greatly  skilled  in  removing  the  points 
of  arrows  from  wounds  in  which  they  have  stuck.  A  counter  opening 
is  often  made  through  which,  after  cutting  off  the  shaft,  the  arrow- 
point  is  withdrawn. 

Appexdix. 
Chronic  mycoses :  Tuberculosis  (scrofula),  syphilis,  leprosy,  actinomycosis. 

§  83.  Tubercnlosis. — Of  the  ckronic  infectious  diseases  of  bacterial 
origin  which  are  of  importance  for  the  surgeon,  tubercnlosis  is  very- 
prominent.  By  tuberculosis  ifrom  tuberculum,  a  nodule)  we  under- 
stand an  infectious  disease  due  to  a  rod-shaped  micro-organism,  the 
Bacillus  tuberculosiis  (Kochj,  and  characterised  anatomically  by  the 
formation  of  nodules,  the  so-called  tubercles.  On  the  2-ith  of  March. 
1SS2,  Robert  Koch  announced  to  the  Physiological  Society  of  Berlin 
that  he  had  found  the  cause  of  tuberculosis,  and  that  the  disease  was 
alone  produced  by  a  single  specific  bacillus  which  he  had  made  grow 
in  pure  cultures.  The  sensation  created  by  Koch's  discovery  was  ex- 
ceedingly great,  and  his  classical  experiments  in  tuberculosis  will 
always  excite  the  profoundest  admii-ation. 

We  shall  here  discuss  mainly  surgical  tuberculosis — that  is,  the 
tuberculosis  coming  within  the  jurisdiction  of  surgical  therapy,  and 
particularly  the  very  common  tuberculosis  of  the  skin,  mucous  mem- 
branes, lymphatic  glands,  sheaths  of  tendons,  bones  and  joints,  etc.    In 


83.] 


TUBERCULOSIS. 


415 


whaterer  part  of  the  boc'y  the  tubercle  bacilh  develop  and  multiply 
they  always  give  rise  to  the  formatiou  of  characteristic  tubercles — that 
is,  to  cellular  nodules  devoid  of  vessels,  which,  after  the  lapse  of  a  defi- 
nite length  of  time  and  in  a  certain  stage  in  their  development,  die, 
usually  by  a  process  of  cheesy  degeneration. 

Origin  and  Structure  of  the  Tubercles. — These  tubercles  (Fig.  334) 
originate,  according  to  the  very  careful  investigations  of  Baumgarten, 
Cornil,  and  others,  in  the  following  manner :  In  consequence  of  the 
growth  of  the  bacilli  in  any  particular  tissue,  there  occurs,  in  the  first 
place,  a  proliferation  of  the  fixed  tissue  cells,  which  begins  with  the 
process  of  caryo mitosis-  and  leads  to  the  formation  of  protoplasmic, 
epithelial-like  or  epithelioid  cells.  The  tubercles  are  consequently 
at  first  made  up  essentially  of 
groups  of  epithelioid  cells  which  ^ 

lie  within  the  connective-tissue 
stroma  of  the  original  tissue, 
which  has  been  partly  absorbed 
and  partly  pushed  aside — the 
so-called  reticulum  of  the  tu- 
bercle. Some  epithelioid  cells 
have  one  nucleus,  others  two, 
while  still  others  are  polynu- 
clear — so-called  giant  cells — in 
which  there  are  often  found  a 
very  great  number  of  large  oval 
nuclei.  The  giant  cells  prob- 
ably originate  not  by  the  fusion 
of  several  epithelioid  cells  but 
by  the  proliferation  of  the  nu- 
clei of  a  single  cell.  In  spite 
of  the  vigorous  growth  of  the 

fixed-tissue  cells  (connective-tissue  cells ;  cells  of  the  walls  of  the  ves- 
sels, epithelium)  no  new  formation  of  capillaries  takes  place  within  the 
nodules.  After  the  proliferation  of  the  original  tissue  cells  there  occur, 
sooner  or  later,  inflammatory  changes  in  the  vessels  of  the  diseased 
region  which  lead  to  an  emigration  of  the  colourless  blood-corpuscles, 
first  in  the  periphery  and  then  later  in  the  centre  of  the  nodules. 
The  nodules,  which  are  at  the  outset  made  up  of  large  cells,  thus  come 
to  be  made  up  more  and  more  of  small  round  cells.  If  the  emigration 
of  leucocytes  occurs  at  a  very  eai*ly  stage  and  masks  the  growth  of  the 
fixed  cells,  it  is  possible  for  the  nodules  to  appear  to  be  made  up  of 
small  cells  from  the  very  beginning      When  the  grey  transparent  nod- 


£ 

Fig.  334. — Tuberculosis  of  lymph  glands:  T,  tu- 
bercle -nith  giant  cells  in  the  centre,  and  large 
celled  tissue  between  the  separate  tubercles ; 
«.  T,  cheesy  tubercle ;  Z,  tissue  of  the  lymph 
gland,  stained  with  haematoxyliu.     x  200. 


416  INFLAMMATION   AND   INJURIES. 

ules,  which  are  about  the  size  of  millet  seeds,  have  reached  the  sta^e  of 
the  small-celled  tubercles  they  are  uo  longer  capable  of  further  devel- 
opment, and  there  now  occurs  a  retrograde  metamorphosis.  The  cells 
either  undergo  fatty  or  cheesy  degeneration  from  lack  of  blood  supply 
or  from  obliteration  of  the  surrounding  vessels  by  thrombosis  and 
endothelial  proliferation,  or  they  break  up  into  homogeneous  masses 
as  in  coagulation  necrosis.  Frequently  the  tubercular  foci  become  per- 
meated with  lime  salts,  and  finally  form  mortar-like  concretions.  The 
typical  death  of  the  tubercle  is  by  caseation  or  cheesy  degeneration 
(Fig.  334:  V.  T.).     The  cause  of  these  tubercles — that  is,  the  cause  of 


® 

CD 

«*    <s® 

®^ 

■is>. 

«"       ^ 

-s^® 

C     ^ 

® 

"^  ^'^  '^        ^ 

ee 

Fig.  335. — Tubercle  bacilli ;  phthisical  sputum  Fig.  336. — Giant  cell  with  tubercle  bacilli 

dried  on  a  cover-glass  and  stained  with  stained  with  Bismarck  brown  and  gen- 

fuchsin  and  methyl-violet,     x  700.  tian  violet,     x  800. 

tuberculosis — is  the  above-mentioned  rod-shaped  bacillus  discovered 
by  R.  Koch  (bacillus  tuhei'culosus^  Fig.  255,  page  261). 

Tubercle  Bacilli. — The  characteristic  bacilli  present  in  the  nodules 
are  found  either  in  the  interior  of  the  cells — for  instance,  within  the 
giant  cells  (Fig.  336) — or  between  the  cells  ;  also  in  the  blood  of  those 
suffering  from  general  tuberculosis,  in  the  sputum  of  those  with  tuber- 
culosis of  the  respiratory  tract,  in  the  urine  in  genito-urinary  tubercu- 
losis, in  pus,  etc.  To  Koch  alone  is  due  the  great  credit  of  having 
proved,  by  inoculations  with  pure  cultures  of  his  bacillus,  that  the 
bacilli  present  in  tuberculosis  are  the  sole  cause  of  the  disease. 

Robert  Koch's  Tubercle  BaciUi.— The  tubercle  bacilli  are  fine,  gen- 
erally slightly  curved  rods  from  1.6  to  .3.5  ^  in  length,  incapable  of  spon- 
taneous movement.  They  usually  occur  singly,  rarely  in  jDairs.  and  some- 
times filaments  are  seen  made  up  of  five  to  six  segments.  Whether  or 
not  the  bacilli  form  spores  has  not  hitherto  been  determined.  "When  the  ba- 
cilli are  stained  there  are  occasionally  seen  bright  vacuoles  having  a  regular 
arrangement,  which  are  suggestive  of  spores.  The  bacilli  are  extremely  re- 
sistant, probably  as  a  result  of  their  very  firm  membrane  or  envelope  ;  hence 


■] 


TUBERCULOSIS. 


4ir 


they  do  not  lose  their  virulence,  though  dried  for  a  month,  or  subjected  to 
high  temperatures  nearly  reaching  the  boiling-point,  or  when  subjected  to 
decomposition  or  the  acid  gastric  juice. 

The  cultivation  of  the  facultative  anaerobic,  strictly  parasitic  bacteria  out- 
side of  the  animal  body  is  accompanied  with  difficulties.    They  thrive  best  of 
all  upon  the  hardened  blood  serum  of  sheep,  cattle,  and 
calves  in  the  incubation  apparatus,  at  a  temperature  of 
37°  to  38°  C.  (98.6°  to  100.4°  F.).     A  tubercle  containing 
bacilli  or  some  similar  substance  taken  from  a  slightly 
caseous  lymph  gland  can  be  used  for  the  seed.     Below 
29°  C.  and  above  42°  C.  tubercle  bacilli  cease  to  grow. 
At  an  incubator  temperature  of  37°  to  38°  C,  if  the  cul- 
ture is  very  carefully  protected   from  impurities  and 
from  becoming  mixed  with  other  bacteria,  there  develop 
upon  the  blood  serum  characteristic  greyish-white,  small 
dry  scales  or  crumbs,  which  become  visible  through  the 
microscope  within  five  to  six  days,  but  to  the  naked  eye 
only  after  the  lapse  of  ten  to  fifteen  days.     From  the 
end  of  the  third  week  on,  the  appearance  is  very  charac- 
teristic.    In  a  test  tube  the  tubercle  bacilli  thrive  ex- 
ceedingly well  upon  meat-peptone  agar  to  which  has 
been  added  three  to  five  per  cent,  of  glycerine  (Nocard, 
Eoux).     This  glycerine  agar  is  at  present  almost  exclu- 
sively used  for  making  pure  cultures,  and  is  displacing 
more  and  more  the  blood  serum  which  is  so  difficult  to 
sterilise.     When  tubercle  bacilli  are  inoculated  with  the 
platinum  wire  upon  glycerine  agar,  the  first  colonies 
will  be   observed  along  the  line  where  the  wire  was 
drawn  about  fourteen  days  subsequently.    If  the  culture 
is  allowed  to  remain  in  the  incubator  for  one  and  a  half 
to  two  weeks  longer  the  typical  picture  of  a  tubercle- 
bacilli  culture  will  be  obtained — that  is,  there  will  be 
seen  upon  the  agar  an  uneven,  greyish- white,  dry,  lustre- 
less mass,  which  is  made   up   of  flakes,  nodules,  and 
small  scales  (Fig.  337).    The  colonies  consist  of  variously 
interlacing  strings  of  bacteria  clinging  together  (Fig. 
338).     Tubercle  bacilli  also  thrive  in  bouillon  to  which 
three  to  five  per  cent,  of  glycerine  has  been  added,  and 
they  have  even  been  cultivated  upon  slices  of  potato 
(made  alkaline)  which  were  kept  from  drying  by  fus- 
ing together  the  open  end  of  the  glass  tube  containing  them  (Globig,  Eoux). 
The  tubercle  bacilli  retain  their  virulence,  though  cultivated  in  artificial 
nutritive  media,  for  a  long  time.     Koch  has  raade  pure  cultures  of  these 
bacilli  grow  in  a  test  tube  for  more  than  nine  years,  and  he  has  observed  only 
a  slight  diminution  of  their  virulence.    The  tubercle  bacilli  must  be  kept  from 
the  light,  as  in  direct  sunlight  they  perish  in  a  few  minutes  or  hours,  accord- 
ing to  the  thickness  of  the  culture.    The  dispersed  daylight  acts  more  slowly. 
Toxine  of  Tubercle  Bacilli.— Koch,  Prudden,  and  others  have  attempted 
to  find  in  the  pure  cultures  of  the  tubercle  bacillus  obtained  from  man  the 


Fig.  337.— Linear  cul- 
ture of  tubercle  ba- 
cilli upon  glycerine- 
agar  five  weeks  old. 


418 


INFLAMMATION   AND   INJURIES. 


Fig.  338.— Colonies  of  tubercle  ba- 
cilli on  coagulated  blood-serum 
X  700. 


active  principle  (toxine)  wliich  causes  the  morbid  conditions  associated  with 
tuberculosis.  According  to  the  discoveries  of  Prudden  and  Hodenpyl,  the 
poisonous  substances  are  not  found,  as  in  many  other  species  of  fungi,  in  the 
nutritive  medium,  but  they  are,  analogous  to  Buciiner's  bacterial  protein, 
fixed  to  the  bodies  of  the  bacilli  in  an  extremely  resistant  form.  The  toxic 
action  of  cultures  of  tubercle  bacilli  lasts,  according  to  Maft'ucci,  about  two 

years  ;  it  is  not  changed  by  subjecting  them 
to  drying  for  fourteen  months,  by  exposing 
them  to  sunlight  for  thirteen  to  fifteen  min- 
utes or  to  the  action  of  a  temperature  of  65° 
to  100°  C.  for  several  hours.  Furthermore, 
they  are  not  changed  for  a  very  long  time 
during  their  sojourn  in  the  human  body. 
Dead  tubercle  bacilli  can  give  rise  to  tuber- 
culosis in  animals,  or  rather  to  chronic  ma- 
rasmus with  nodules  resembling  tubercles  in 
the  lungs,  with  pneumonic  processes,  thick- 
ening of  the  intima  of  tlie  vessels,  etc.  Com- 
plete recovery  from  tuberculosis  is  not  ob- 
tained by  the  death  of  the  tubercle  bacilli, 
but  the  tubercular  foci  containing  the  dead 
bacilli  must  likewise  be  done  away  with  or 
the  tubercular  poison  itself  rendered  harmless.  In  fact,  dead  tubercle  bacilli 
are  said  by  Babes  and  Proca  to  contain  more  toxines  than  the  living,  because 
certain  toxines  are  formed  only  in  the  dying  bacilli,  and  are  more  easily  set 
free  from  the  dead  bacilli  than  from  the  living.  The  cachexia  of  phthisical 
patients  is  caused  mainly  by  the  toxic  substances  formed  by  the  tubercle 
bacilli.  Richet  and  Hericourt  have  obtained  from  tubercular  cultures  a 
toxine  which  has  a  toxic  effect  upon  tubercular  rabbits,  but  none  at  all  upon 
healthy  ones. 

The  poisonous  action  of  tubercle  bacilli  is  combated  by  certain  protec- 
tive substances  (antitoxines)  which  are  produced  in  the  animal  body.  These 
antitoxines,  which  are  also  present  in  the  cultures  of  tubercle  bacilli,  have  a 
pi'otective  and  curative  action  upon  tubercular  processes.  For  a  description 
of  Koch's  tuberculin  see  page  431. 

Staining  of  Tubercle  Bacilli. — Different  methods  have  been  recommended 
for  staining  tubercle  bacilli.  The  examination  of  sputum  for  tubercle  bacilli 
is  as  follows  :  A  portion  of  one  of  the  ordinary  yellow,  tenacious  lumps  is 
taken  from  a  mass  of  sputum,  transferred  to  a  cover-glass,  upon  which  is 
then  placed  a  second  cover-glass,  and  the  material  to  be  examined  is  pressed 
between  them.  The  cover-glasses  ai'e  then  removed  from  one  another,  al- 
lowed to  dry  in  the  air,  and  passed  three  times  through  a  flame.  While  the 
cover-glass  is  held  by  thumb  forceps,  a  drop  of  carbolised  fuchsin  is  placed 
upon  it,  the  preparation  is  held  a  moment  over  the  flame,  and  this  procedure 
is  repeated  several  times,  fresh  staining  solution  being  added  if  necessary. 
Then  the  stain  is  washed  off  with  distilled  water.  The  parts  surrounding 
the  bacteria  are  decolorised  with  fifteen  to  twenty  per  cent,  nitric  acid  by 
moving  the  cover-glass  back  and  forth  a  few  moments  in  the  latter  until  the 
deep-red  jDreparation  becomes  greenish  blue.     Then  the  dissolved  fuchsin  is 


§  83.]  TUBERCULOSIS.  419 

washed  away  in  seventy  per  cent,  alcohol,  and  the  preparation  is  rinsed  in 
distilled  water  and  re-stained  with  methylene  blue,  by  which  everything  is 
coloured  blue  except  the  bacilli,  which  still  remain  red.  After  washing  in 
water  the  preparation  can  be  examined  immediately,  or  it  may  be  dried, 
and  mounted  in  Canada  balsam. 

Of  the  other  methods  of  staining  I  should  mention  i^articularly  B. 
Frankel's,  which  is  the  best  of  the  remaining  ones,  and  can  be  quickly  carried 
out.  (Staining  with  hot  carbolised  fuchsin,  then  decolorising  and  counter- 
staining  in  a  solution  of  fifty  parts  water,  thirty  i^arts  alcohol,  twenty  parts 
nitric  acid,  and  methylene  blue  to  saturation,  washing  in  water.)  Gram's 
method  is  also  useful.  By  the  above-mentioned  rules  a  stain  can  be  given  to 
sputum,  fseces,  pus  from  a  wound,  samples  of  jjure  cultures,  etc.  The  stain- 
ing of  a  section,  and  consequently  of  the  tubercle  bacilli  in  the  tissues,  is 
done  in  essentially  the  same  manner  (for  instance,  immersion  for  one  hour 
in  carbolised  fuchsin,  decolorising  in  dilute  [ten  per  cent.J  nitric  acid  for 
about  one  half  to  one  minute,  washing  in  seventy  per  cent,  alcohol,  counter- 
staining  in  methylene  blue  for  two  to  three  minutes,  dehydrating  in  absolute 
alcohol,  clarifying  in  oil,  and  mounting  in  Canada  balsam.)  Ehrlich's  aque- 
ous aniline-dye  solutions  are  also  much  used  for  sections  and  cover-glass 
preparations.  (At  ordinary  temperatures  the  object  is  immersed  for  at  least 
twelve  hours  in  Ehrlich's  solution  [aniline- water,  fuchsin,  or  gentian  violet], 
at  higher  temperatures  for  a  shorter  time,  then  for  a  few  seconds  it  is  washed 
in  twenty-five  per  cent,  nitric  acid,  and  for  several  minutes  in  sixty  per  cent, 
alcohol,  then  double  stained  in  Bismarck  brown  or  a  methylene-blue  solu- 
tion, depending  upon  whether  it  was  first  stained  with  violet  or  fuchsin,  then 
washed  in  sixty  per  cent,  alcohol  and  dehydrated  in  absolute  alcohol,  clai-i- 
fied  in  oil  of  cedar,  and  mounted  in  Canada  balsam.)  It  is  of  practical  im- 
portance to  differentiate  tubercle  bacilli  from  the  smegma  bacilli  which  are 
so  common  on  the  external  surface  of  the  body.  For  this  purpose  Bunge 
and  Trautenroth  recommend  a  complicated  decolorising  method,  consist- 
ing in  treating  the  preparation  with  alcohol  and  chromic  acid  before  stain- 
ing it  with  carbol  fuchsin. 

Transmission  of  Tuberculosis  to  Animals. — The  transmissibility  of  tuber- 
culosis to  animals  by  inoculation,  by  intravenous  injection,  and  by  allowing 
them  to  eat  and  inhale  tuberculous  substances,  had  been  proved  by  Klencke 
in  1843,  before  Koch's  epoch-making  experiments  had  been  made.  Yillemin 
(1865-'68)  was  the  first  to  demonstrate  by  systematic  experiments  that  tuber- 
culosis can  be  transmitted  from  man  to  animals,  and  from  animal  to  animal. 
These  experiments  were  then  repeated  with  positive  results,  particularly  by 
Chauveau,  Cohnheim,  Klebs,  and  others.  Then  Robert  Koch  showed  that 
tuberculosis  could  only  be  transmitted  to  animals  by  inoculation,  by  intra- 
venous injection,  and  by  inhalation  when  the  material  employed  contained 
tubercle  bacilli.  In  the  first  place,  Robert  Koch  repeated  many  times  suc- 
cessfully the  inoculation  experiments  which  had  been  performed  upon 
guinea-pigs,  rabbits,  etc.,  with  portions  of  tubercular  tissue  (nodules  of  mili- 
ary tuberculosis,  tubercular  pus,  phthisical  sputum,  fungous  material  from 
joints,  luiDus,  portions  of  scrofulous  glands,  nodules  of  bone  tuberculosis). 
He  then  employed  in  a  great  number  of  transmission  experiments  pure 
cultures  of  tubercle  bacilli,  and  by  inoculating  these  into  the  subcutaneous 


420  INFLAMMATION  AND  INJURIES. 

tissue,  into  the  anterior  chamber  of  the  eye,  and  by  injecting  them  into  the 
peritoneal  cavity  and  into  the  veins,  and  by  causing  them  to  be  inhaled,  he 
produced  true  tuberculosis,  with  its  characteristic  bacilli,  which  could  be 
again  and  again  successfully  transmitted  to  other  animals.  So  Koch  has 
furnished  in  the  most  convincing  manner  the  indisputable  proof  that  tuber- 
culosis is  caused  by  specific  bacilli.  Koch's  admirable  work  will  be  found 
in  the  Mittheilungen  des  Kaiserlichen  Gesundheitsamtes,  1884.  Almost  at 
the  very  same  time  that  Koch  published  his  work  upon  the  etiology  of  tuber- 
culosis, Baumgarten,  independently  of  Koch,  had  likewise  found  bacilli  in 
the  tubercles  produced  in  rabbits  by  inoculation,  but  he  did  not  make  cultures 
and  inoculations  with  them. 

All  animals  are  not  equally  susceptible  to  tubercle  bacilli.  Guinea-pigs, 
rabbits,  and  ruminants  have  a  pronounced  predisposition  for  tuberculosis, 
while  dogs,  rats,  and  white  mice  are  immune  from  it.  It  is  well  known  that 
man, shows  great  variations  in  susceptibility  to  the  poison  of  tuberculosis. 
Morrihy  made  the  interesting  observation  that  guinea-pigs  which  were 
inoculated  with  the  toxines  of  tubercle  bacilli  and  of  the  Bacterium  coli 
commune  did  not  acquire  tuberculosis.  Babes  and  Friedrich  observed  forma- 
tions similar  to  the  ray  fungus  in  animals  which  were  killed  within  twenty- 
five  days  after  injecting  into  the  common  carotid  salt  solution  containing  a 
small  quantity  of  tubercle  bacilli.  These  did  not  appear  in  animals  that 
were  killed  over  thirty  days  after  infection. 

Tuberculosis  of  Cattle.— The  tuberculosis  of  cattle,  in  which  small  and 
large  nodules,  even  reaching  the  size  of  a  walnut  or  potato,  are  formed,  is, 
according  to  recent  investigations,  identical  with  the  tuberculosis  of  man, 
and  the  pi'esence  of  tubercle  bacilli  has  likewise  been  demonstrated.  Inocu- 
lation experiments  have  also  given  corresponding  results.  By  the  ingestion 
of  meat  and  milk  containing  tubercle  bacilli  from  tubercular  cows  (particu- 
larly those  with  local  tubercular  disease  of  the  udder),  tuberculosis  may 
easily  be  caused  in  man.  If  boiled,  the  virulence  of  infected  milk  is  de- 
stroyed ;  its  poisonous  character  may  be  weakened  by  diluting  it  with  milk 
which  is  free  from  bacteria  (Bollinger). 

Pseudo-Tuberculosis. — Eberth  has  described  a  pseudo-tuberculosis  of 
guinea-pigs.  Changes  simulating  tuberculosis  are  found  particularly  in  the 
abdominal  organs,  especially  in  the  liver,  and  to  a  less  extent  in  the  lungs. 
Some  of  the  nodules  present  the  api^earance  of  miliary  tubercles,  others  of 
small  abscesses.  In  the  centre  of  the  nodules  collections  of  micrococci  are- 
found,  and  the  nodules  themselves  apj)ear  microscopically  either  as  spots  of 
coagulation  necrosis,  surrounded  by  a  zone  of  leucocytes,  or  as  collections  of 
pus.  The  tuberculose  zoogloeique  of  Malassez  and  Vignal  is  probably  iden- 
tical with  this  pseudo-tuberculosis.  Ebei'th  also  observed  a  tubercle-like  dis- 
ease— a  pseudo-tuberculosis — in  rabbits,  and  he  found  the  micro-organisms  to 
be  small,  short  rods,  double  the  width  of  tubercle  bacilli  and  rounded  at  the 
ends,  forming  chains  made  up  of  shorter  or  longer  segments,  which  were 
either  placed  side  by  side  or  twisted  together  in  groups  and  collected  in  thick 
clusters.  Eppinger  found  a  cladothrix  form  to  be  the  excitant  of  pseudo- 
tuberculosis in  man. 

The  Tubercle  Bacillus  of  Birds.— The  weakened  (attenuated)  or  virulent 
tubercle  bacillus  of  birds,  cultivated  in  a  liquid  of  slight  nutritive  powers, 


* 

§  83.]  TUBERCULOSIS.  421 

furnishes  substances,  according  to  Courmont  and  Dor,  by  means  of  which 
rabbits  can  be  made  immune  from  the  effects  of  inoculation  with  the  tubercle 
bacillus  of  man. 

Combination  of  Tuberculosis  with  Carcinoma  and  Syphilis.— In  rare  cases 
there  has  been  observed  the  simultaneous  occurrence  of  carcinoma  and 
tuberculosis  in  the  same  portion  of  the  body ;  for  instance,  an  eruption  of 
tubercles  may  be  found  in  the  neighbourhood  of  a  cai'cinoma  of  the  stomach 
or  larynx.  In  such  instances  the  tubercle  bacilli  have  gained  access  to  the 
surrounding  tissues  through  the  carcinomatous  ulceration  (Zenkel,  Hof- 
mokl,  and  others).  Ribbert  believes  that  tuberculosis  is  the  cause  in  some 
carcinomata  of  the  formation  of  the  primary  subepithelial  granulation  tissue 
described  by  him  (see  Carcinoma).  The  simultaneous  occurrence  of  syphilis 
and  tuberculosis  is  also  interesting ;  the  syphilitic  product,  for  example,  may 
gradually  take  on  a  tubercular  character  from  the  lodgment  of  tubercle 
bacilli  (Eisenbei'g,  Leloir).  In  consequence  of  such  a  mixed  tubercular- 
syphilitic  infection,  there  will  be  observed  corresponding  affections — for 
instance,  of  the  lymphatic  glands  and  skin — which  will  only  partially  dis- 
appear under  antisyphilitic  treatment.  According  to  Hochsinger,  syphilis 
and  tuberculosis  occur  as  a  mixed  infection  even  in  infants,  and,  in  fact,  this 
mixed  infection  may  be  congenital. 

Origin  of  Tuberculosis  in  Man. — In  the  first  place,  individua]  predis- 
position, which  may  be  congenital  or  acquired,  is  of  particular  impor- 
tance in  the  acquirement  of  tuberculosis  by  man.  This  predisjDOsition 
is  due  to  general  constitutional  conditions  and  to  local  changes  in  the 
tissues,  and  especially  to  variations  in  the  metabohsm  of  the  tissues 
exhibited  by  some  individuals,  as  well  as  a  change  in  the  irritability  of 
the  cells.  Foremost  in  this  category  stands  scrofula,  a  congenital  or 
acquired  constitutional  disturbance  of  nutrition.  Climatic  and  other 
conditions  peculiar  to  certain  regions  are  also  of  great  importance.  In 
many  places,  such  as  certain  high  ■  resorts  or  regions  where  lime  in- 
dustries exist,  tuberculosis  is  almost  unknown. 

The  tubercle  bacilli  or  their  spores,  whose  existence  is  still  doubt- 
ful, are  contained  in  the  atmospheric  air,  into  which  they  get  from  the 
excretions,  or  the  sputum,  etc.,  of  animals  or  man  affected  with  tuber- 
cular disease.  Tubercle  bacilli  are  found  particularly  in  the  dust  or 
the  air  in  which  phthisical  sputum  has  opportunity  to  dry  and  be- 
come dispersed.  They  are  also  carried  about  by  flies  (Spillmann, 
Haushalter).  To  put  a  prophylactic  restraint  upon  tuberculosis  it  is 
advisable  first  of  all  to  introduce  cuspidors  into  more  general  use,  pro- 
vided with  a  solution  of  bichloride  of  mercury  (Cornet).  Healthy 
people  can  very  easily  become  infected  with  tuberculosis  by  constant 
contact  with  unclean  phthisical  individuals.  Tubercle  bacilli  are  taken 
into  the  body  chiefly  by  the  lungs  ;  they  also  are  taken  into  the  intes- 
tine with  the  food,  or  they  find  entrance  through  an  interruption  in  the 


422  INFLAMMATION  AND   INJURIES. 

continuitv  of  the  skin,  through  fresh  wounds,  etc.  Tuberculosis  pro- 
duced by  inoculation  into  very  small  wounds  or  cutaneous  abrasions 
is  observed  particularly  on  the  hands  of  physicians,  students,  nurses, 
dead-house  attendants,  washerwomen,  etc.  According  to  Baumgarten, 
Tangl,  and  others,  the  bacilli,  as  the  result  of  their  growth  and  multi- 
plication, always  form  at  the  point  where  they  were  absorbed,  a  local 
tubercular  focus  of  inflammation.  They  may  also  gain  access  to  the 
circulation,  and  by  it  be  carried  into  the  internal  organs,  particularly 
the  lymph  glands  and  bones  (the  marrow).  The  tubercular  affection 
is,  at  the  outset,  always  purely  local  (Baumgarten,  Pontick),  but  if  the 
poison  gets  into  the  general  circulation  and  so  is  distributed  through- 
out the  system,  general  miliary  tuberculosis,  or  a  flooding  of  the  body 
as  it  were  with  bacilli,  can  take  place. 

Local  tultercular  disease  originates  with  preference  in  the  places 
where  the  tubercle  bacilli  easily  find  lodgment  and  are  not  mechanic- 
ally swept  away,  as  in  the  lungs,  the  lymph  glands,  in  the  capillai'ies  of 
the  bone  marrow  which  have  no  walls,  in  terminal  vessels,  and  espe- 
cially in  blood  extravasations.  According  to  Robert  Koch,  tuberculosis 
in  man  originates  most  frequently  in  the  lungs.  It  is  a  matter  of  im- 
portance for  the  surgeon  to  know  that  tuberculosis  of  the  skin  and 
lymph  glands  can  result  from  scratches,  cutaneous  eruptions,  and  ulcers 
in  the  skin.  Czei-ny  saw  two  cases  which  had  been  inoculated  with 
tuberculosis  by  skin  transplantation.  Embolic  tuberculosis  of  different 
organs,  particularly  the  bones  and  joints,  frequently  originates  from 
tubercular  bronchial  glands. 

Extension  of  Tubercular  Inflammation. — The  extension  of  the  tubercu- 
lar inflammation,  which,  as  we  have  said,  is  at  the  outset  purely  local,  is 
dependent  upon  the  multiplication  of  the  bacilli.  The  extension  either 
proceeds  steadily  by  contiguity,  or  the  wandering  cells  carry  the  bacilli 
into  the  adjoining  parts  and  there  form  new  foci,  which  either  re- 
main isolated  or  gradually  coalesce  with  the  primary  focus.  By  the 
entrance  of  living  bacilli  into  the  circulation  (blood,  lymph)  the  tuber- 
cular inflammation  may  be  distributed  throughout  the  entire  body. 
We  observe  an  extension  of  the  tubercular  inflammation  by  contiguity 
when,  for  example,  a  tubercular  inflammation  of  the  bone  marrow 
breaks  through  the  bone  and  infects  a  neighbouring  joint.  In  a  simi- 
lar manner  the  large  serous  cavities  become  diseased,  usually  by  direct 
extension  of  the  tubercular  inflammation  from  one  of  the  organs  that 
form  their  walls  (TVeigert).  Thus  tubercular  pleurisy  originates,  in 
the  majority  of  instances,  from  a  small  pulmonary  focus  extending  to 
the  pleura,  or  from  tubercular  disease  of  the  vertebra?,  ribs,  or  lymph 
glands.    Tuberculosis  of  the  peritouasum  is  most  frequently  observed  in 


§  83.]  TUBERCULOSIS.  423 

conjunction  witli  a  tuberculosis  of  the  intestine,  tlie  female  organs  of 
generation,  etc.  Deposition  of  the  poison  directly  from  the  blood  into 
the  serous  cavities  seldom  takes  place.  Occasionally  the  extension  of  the 
tuberculosis  can  be  traced  along  the  lymph  channels.  In  such  cases 
there  will  be  observed  a  corresponding  formation  of  nodules  in  the 
course  of  the  lymphatic  vessels.  From  the  lymph  channels  the  poison 
passes  into  the  lymph  glands,  then  through  the  thoracic  duct  into  the 
blood-vessels ;  or  it  may  break  into  a  vein  directly,  and  in  such  cases 
cause  a  general  distribution  of  the  bacilli  all  through  the  system,  so 
that  nodules  occur  everywhere  (general  miliary  tuberculosis),  and  then 
death  usually  follows  in  a  short  time. 

In  fourteen  cases  of  general  miliary  tuberculosis,  Weigert,  by  care- 
fully examining  the  veins,  was  able  thirteen  times  to  demonstrate  the 
place  where  the  poison  broke  through  into  the  veins,  or  into  the  tho- 
racic duct,  in  the  form  of  tubercular  thrombi.  JN^ot  infrequently  there 
is  an  extensive  formation  of  tubercles  in  the  walls  of  the  vessels.  The 
bacilli  occasionally  lodge  in  the  intima  of  the  thoracic  duct  itself.  In 
such  cases  there  is  observed  a  cheesy  ulceration  of  the  intima  of  the 
duct  (Ponfick). 

Detection  of  Tubercle  Bacilli.— The  detection  of  the  tubercle  bacilli 
is,  as  we  have  remarked,  of  the  greatest  importance  for  diagnostic  pur- 
poses, particularly  when  found  in  the  blood  in  general  tuberculosis,  in  the 
sputum  in  tuberculosis  of  the  respiratory  tract,  in  the  evacuations  from  the 
bowel  in  intestinal  tuberculosis,  in  the  urine  in  genito-urinary  tuberculosis, 
and  in  the  pus  in  tubercular  disease  of  bones,  joints,  and  soft  parts.  The 
bacilli  can  be  most  easily  demonstrated  in  the  sputum  when  they  find  a 
medium  favourable  for  their  nutrition,  and  can  keep  on  multiplying  second- 
arily. According  to  Robei't  Koch,  the  bacilli  are  particularly  apt  to  be  found 
where  the  tubercular  process  is  in  its  inception,  the  cheesy,  suppurating 
products,  as  a  general  rule,  containing  but  few  bacilli.  Very  often  the  tu- 
bercle bacilli  cannot  be  demonstrated  in  tubercular  pus  ;  nevertheless,  guinea- 
pigs  inoculated  with  this  pus  will  die  of  tuberculosis.  The  giant  cells,  in  a 
process  which  has  lasted  a  long  time,  will  contain,  for  the  most  part,  only  a 
few  bacilli. 

Termination  of  the  Tubercular  Inflammation. — Wherever  they  may 
occur,  both  the  nodules  and  the  diffuse  tubercular  infiltration  disinte- 
grate and  undergo  cheesy  degeneration.  In  this  way,  particularly  in 
the  skin  and  mucous  membranes,  tubercular  ulcers  are  formed  with  a 
cheesy  or  caseous  base  after  the  inflammatory  processes  have  broken 
through  externally.  In  other  cases,  particularly  in  tuberculosis  of  the 
bones  and  joints,  extensive  suppuration  occurs.  The  pus  in  the  latter 
process  has  characteristic  properties ;  it  is  usually  thin,  and  contains 
cheesy  masses.    Occasionally,  as  in  tubercular  inflammation  of  the  ver- 


424  INFLAMMATION   AND   INJURIES. 

tebr£e,  extensive  abscesses  develop,  ^vliicli  gradually  sink  downwards 
along  the  connective-tissue  spaces.  These  are  called  congestion  or  cold 
abscesses  (see  Tuberculosis  of  Bone).  In  the  bones  and  joints  the  dis- 
turbances excited  bj  the  tuberculosis,  as  we  shall  see  later  on,  are  very 
considerable. 

The  tubercular  suppuration  is  mainly  due  to  the  tubercle  bacilli, 
though  in  many  cases  there  is  a  mixed  infection  with  pus  cocci — the 
staphylococcus  and  streptococcus. 

A  reactive  inflammation  usually  takes  place  around  the  tubercular 
focus,  encapsulating  the  latter,  the  organism  trying  in  this  way  to  ])ro- 
tect  itself  from  further  infection.  The  single  foci  of  tubercular  in- 
flammation may  entirely  heal,  and  they  do  this  the  more  readily  the 
smaller  they  are  and  the  earlier  and  more  completely  they  are  removed 
by  operative  measures.  Spontaneous  healing  of  tuberculosis  is  due  to 
a  reactive  inflammation  in  the  neighbourhood  of  the  tubercular  inflam- 
mation. The  cheesy  masses  become  absorbed  or  encrusted  with  the 
salts  of  lime,  the  bacilli  gradually  die,  and  firm  connective  tissue  takes 
the  place  of  the  tubercular  material.  But  there  is  always  the  danger 
that  the  tubercular  inflammation  may  break  out  afresh  as  long  as  bacilli 
capable  of  development  remain  enclosed  in  the  original  focus  of  infec- 
tion. The  bacilli,  or  rather  their  spores,  appear  to  have  great  powers 
of  resistance,  which  exj)lains  why  tubercular  inflammation  recurs  with 
such  extraordinary  frequency.  The  greater  the  number  of  the  foci  of 
disease,  so  much  the  more  improbable  is  the  recovery.  All  too  often 
the  latter  is  only  apparent  or  temporary,  and  then  suddenly  the  disease 
appears  afresh.  Every  individual  who  has  shown  his  susceptibility 
to  the  poison  of  tuberculosis  by  having  had  one  attack  of  the  disease  is 
always  in  danger  of  a  new  outbreak. 

Inheritance  of  Tuberculosis. — An  important  question  for  the  physician  is 
whether  tuberculosis  can  be  inherited — that  is.  Avhether  the  tubercle  bacillus 
is  transmitted  from  the  parents  to  the  foetus,  either  at  the  time  of  conception 
or  during  its  intra-uterine  life. 

Recent  experiments  and  clinical  observations  upon  animals  prove  the  oc- 
currence of  a  congenital  tuberculosis  in  animals.  Johne,  Hertvig,  and  Csokor 
found  tubei'cle  bacilli  in  the  foetus  of  cattle.  Koubassoff  infected  pregnant 
guinea-pigs  with  tubercle  bacilli ;  both  the  mother  and  the  foetus  became 
tubercular,  and  tubercle  bacilli  were  found  in  each.  Landouzy  and  Martin 
have  also  proved  experimentally  the  existence  of  congenital  tuberculosis. 
In  man  also  the  occurrence  of  tuberculosis  developing  in  utero  has  been  ob- 
served. Tubercle  bacilli  have  been  found  in  the  blood  and  internal  organs  of 
infants,  but  usually  without  tubercles,  the  latter  not  developing  until  after 
birth. 

Foetal  tuberculosis  in  man  is,  however,  rare  ;  it  can  result  from  tubercle 
bacilli  in  the  spermatic  fluid  in  case  of  tuberculosis  of  the  geuito-uriuary 


§  83.]  TUBERCULOSIS.  425 

tract,  and  in  case  of  tubercle  bacilli  in  the  blood  of  the  father.  It  is  well 
known  that  children  of  tubercular  parents  easily  contract  tuberculosis  after 
birth,  and  hitherto  it  has  been  believed  that  tuberculosis  always  oi'iginates 
after  birth,  because  the  children  in  question  inherit  a  predisposition  for  it  and 
are  exposed  to  a  marked  extent  to  infection  by  contact  with  their  parents.  I 
have  no  doubt  that  some  cases  of  tuberculosis  apparently  originating  after 
birth  have  already  begun  in  utero,  and  consequently  are  of  congenital  origin. 
This  has  been  recently  confirmed  by  observations  made  by  Birch-Hirschfeld. 
He  demonstrated  that  the  tubercle  bacillus  has  the  power  of  passing  through 
the  walls  of  the  vessels  from  the  maternal  into  the  foetal  circulation.  He  had 
one  case  of  a  twenty -three-year-old  woman  who  had  died  of  miliary  tuber- 
culosis in  the  seventh  month  of  pregnancy.  In  the  placenta  there  were 
found,  in  the  intervillous  spaces  and  in  the  interior  of  the  vessels  of  the  villi, 
many  tubercle  bacilli ;  they  were  also  found  in  the  liver  of  the  foetus.  Inocula- 
tions made  with  portions  of  the  foetal  organs  produced  tuberculosis  in  guinea- 
pigs.  Birch-Hirschfeld  still  holds  to  the  general  opinion  that  under  normal 
conditions  the  placenta  is  impervious  for  finely  divided  foreign  bodies  or 
micro-organisms,  but  by  pathological  processes,  or  rather  by  the  lodgment 
of  micro-organisms,  this  filter  is  made  pervious.  The  bacilli,  as  it  were,  grow 
into  the  foetal  portion  of  the  placenta  in  the  same  way  that  the  anthrax 
bacilli  enter  the  pulmonary  vessels  after  the  inhalation  of  anthrax  spores 
which  Buchner  demonstrated  experimentally. 

Brief  Review  of  Tubercular  Disease  in  the  Various  Tissues  and  Organs 
as  far  as  it  concerns  the  Surgeon. — Concerning  the  clinical  course  of 
surgical  tuberculosis,  the  following  brief  statement  will  suffice : 

Tuberculosis  of  the  Skin  and  Subcutaneous  Cellular  Tissue. — Tubercu- 
losis of  the  external  cutaneous  covering  and  of  the  cellular  tissue  is  of 
frequent  occurrence.  The  so-called  lupus  (§  93,  Chronic  Inflammations 
of  the  Skin)  is  a  special  form  of  tuberculosis  of  the  skin.  Lupus  occurs 
alone,  or  it  may  be  a  part  of  a  tubercular  constitutional  affection. 
Other  tubercular  ulcerations  of  the  skin  occur,  particularly  in  children 
and  young  individuals,  either  primary  or  secondary,  for  instance,  to 
tubercular  abscesses  of  the  lymph  glands  and  tubercular  bone  and  joint 
disease.  These  tubercular  ulcerations  of  the  skin  usually  yield  readily 
to  surgical  treatment.  Yarious  exanthematous  skin  lesions  occur  in 
the  skin  of  tuberculous  patients  which  are  probably  caused  by  the  tox- 
ines  of  the  tubercle  bacilli,  as  the  latter  can  usually  not  be  demonstrated 
in  the  lesions  (Boeck).  In  this  category  belong  lichen  scrophulosorum, 
several  forms  of  eczema  (eczema  scrophulosorum),  lupus  erythematosus 
discoides  sen  disseminatus,  etc. 

The  so-called  anatomical  tubercle  described  in  §  T6  is  occasionally, 
though  not  always,  a  true. tuberculosis  of  the  skin. 

Primary  tuberculosis  of  the  panniculus  adiposus,  particularly  in 
young  children,  takes  the  form  of  firm,  flat,  subcutaneous  nodes,  which 
gradually  extend,  coalesce,  and  break  through  externally  after  the  skin 
30 


426  INFLAMMATION  AND  INJURIES. 

lias  necrosed.  In  other  cases  they  may  evince  a  preference  to  grow 
into  the  deeper  parts  beneath  the  more  or  less  uninjured  skin. 

Primary  tuberculosis  and  primary  tubercular  abscesses  of  the  deep 
intermuscular  spaces  and  connective  tissue  in  the  neighbourhood  of 
bones  and  joints  are  very  rare.  Tuberculosis  in  these  regions  is  usually 
secondary  to  tubercular  disease  of  the  bones,  joints,  and  lymph  glands. 
In  this  category  should  be  classed  the  congestion  abscesses — that  is,  the 
so-called  cold  abscesses  following  tubercular  disease  of  the  boues  or  the 
joints,  particularly  those  of  the  vertebral  column. 

Tubercular  abscesses  are  very  fi-equently  observed.  They  are  usu- 
ally enclosed  by  a  characteristic  greyish  or  yellowish-grey  membrane — 
the  so-called  abscess  membrane — containing  miliary  tuljercles.  This 
membrane  can  be  easily  loosened  or  scratched  oif  from  the  healthy 
adjoining  parts.  Only  in  rare  instances  is  there  seen  a  diffuse  spread- 
ins:  of  the  tubercular  inflammation  into  the  muscular  tissue.  The 
above-mentioned  abscess  membrane  is  only  observed  in  tuberculosis, 
and  is  consequently  of  diagnostic  importance.  It  is  lacking  in  syphilis, 
in  which,  in  general,  there  is  more  frequently  observed,  in  contradis- 
tinction to  tuberculosis,  a  diffuse  cheesy  degeneration  of  the  muscles, 
for  instance. 

Tuberculosis  of  Mucous  Membrane — The  Tongue. — Among  tubercu- 
lar affections  of  the  exposed  mucous  membranes  there  is  observed  a 
tuberculosis  of  the  tongue  which  sometimes  takes  the  form  of  a  partly 
torpid,  partly  fungous  ulceration,  and  at  others  of  a  deep-seated  node 
with  central  softening.  The  tubercular  ulcer  of  the  tongue,  with  an 
indurated  area  surrounding  it,  may  sometimes  be  mistaken  for  cancer, 
and  tubercular  nodes  have  a  similarity  to  syphilitic  gummata,  but 
their  local  manifestations  and  the  whole  clinical  course  will,  in  the 
majority  of  cases,  assure  the  correct  diagnosis.  In  one  case  I  saw 
the  entire  superficial  surface  of  the  tongue  covered  with  tubercular 
ulcers,  varying  in  size  from  that  of  a  pin-head  to  that  of  a  pea,  and 
between  them  miliary  tubercles  were  everywhere  visible.  The  great 
majority  of  patients  operated  upon  for  tuberculosis  of  the  tongue  sub- 
sequently die  of  pulmonary  tuberculosis  ;  but  still  some  complete  re- 
coveries have  been  recorded  even  in  individuals  strongly  predisposed 
by  heredity. 

Tuberculosis  of  the  Pharynx  and  Palate  occurs  mainly  in  tubercular 
children  at  the  age  of  puberty  and  soon  after,  in  the  form  of  ulcers  the 
size  of  a  pea  and  larger,  having  a  tendency  to  coalesce,  and  located  on 
the  palatine  arches,  the  posterior  wall  of  the  pharynx,  and  the  pos- 
terior surface  of  the  velum  palati.  Between  the  ulcers  there  do  not 
often  fail  to  be  miliary  nodules,  which  are  visible  when  the  illumina- 


§83.]  TUBERCULOSIS.  42Y 

tion  is  sufficient.  Tuberculosis  of  the  pharynx  and  palate  is  very  apt 
to  be  confused  "vvith  syphilis.  In  the  differential  diagnosis  it  is  to  be 
noted  that  syphilis  produces  more  loss  of  substance,  while  tuberculosis 
is  more  apt  to  give  rise  to  extensive  ulcerating  surfaces  which  have  a 
tendency  to  shrink  and  contract.  In  this  condition  permanent  recov- 
eries have  also  undoubtedly  been  obtained,  but  the  majority  of  the 
patients  die  of  pulmonary  tuberculosis. 

Nose. — Tuberculosis  of  the  nasal  mucous  membrane  fozsena  tuber- 
cularis)  occurs  in  the  form  of  a  primary  tubercular  ulceration  of  the 
mucous  membrane,  or  secondary  to  primary  tuberculosis  of  the  bones, 
particularly  the  superior  maxilla. 

Lips. — Severe  tubercular  ulcerations  occasionally  make  their  appear- 
ance upon  the  lips. 

Rectum. — Some  fistulse  of  the  rectum  are,  as  the  ancient  physicians 
well  knew,  tubercular  in  character.  The  tubercular  rectal  fistula  is 
characterised  by  a  tendency  to  the  formation  of  fungous  granulations, 
by  an  extensive  lifting  up  of  the  mucous  membrane  from  the  under- 
lying parts,  undermining  of  the  skin,  and  by  the  formation  of  abscesses 
with  sinuses.  ,The  prognosis  of  tubercular  rectal  fistula  is  very  un- 
favourable. 

Intestine. — Tubercular  perityphlitis  occurs  after  perforation  of  a 
tubercular  intestinal  ulcer.  It  gives  rise  to  large  tubercular  abscesses, 
and  yet  patients  who  have  them  are  often  otherwise  entirely  well. 

Genito-urinary  Tuberculosis. — It  has  been  my  experience  to  find  that 
tuberculosis  of  the  genito-urinary  apparatus  runs  a  particularly  unfa- 
vourable course,  sometimes  with  great  rapidity.  Tuberculosis  of  the 
testicle  and  epididymis — originating  either  primarily  or  secondarily  to 
tuberculosis  of  the  vas  deferens  or  the  genito-urinary  apparatus — usu- 
ally occurs  in  young  or  middle-aged  men,  and  even  old  men  are  not 
exempt.  In  general  it  is  best,  as  soon  as  possible,  to  remove  the  tuber- 
cular focus  in  order  to  prevent  the  process  from  involving  the  other 
testicle  or  the  spermatic  cord,  prostate,  and  bladder.  Tuberculosis  of 
the  spermatic  cord  is  characterised  by  an  even  thickening  or  a  nodular 
swelling  in  the  course  of  the  vas  deferens.  Tuberculosis  of  the  blad- 
der, ui-ethra,  and  kidneys  is  very  typical,  and  belongs  to  the  severest  of 
the  tubercular  diseases.  Tuberculosis  of  the  bladder  has  hitherto  re- 
sisted all  attempts  to  cure  it.  The  demonstration  at  an  early  period  of 
tubercle  bacilli  in  the  urine  is  of  great  practical  importance.  For 
tuberculosis  of  the  kidney  or  its  pelvis,  it  is  best,  at  as  early  a  stage  as 
possible,  to  undertake  operative  treatment  in  the  form  of  nephrotomy 
or  nephrectomy.  I  must  refer  the  reader  to  my  text-book  of  special 
surgery  and  to  the  text-books  on  gynaecology  for  tuberculosis  of  the 


428  INFLAMMATION  AND  INJURIES. 

penis,  vagina,  and  uterus.  In  rare  instances  inoculation  with  tubercu- 
losis may  take  place  on  the  external  genitals  as  a  i-esult  of  coitus 
(Kraske,  Schmidt).  Tul)erculosis  of  the  mamma  is,  according-  to  Bill- 
roth, Yolkmann,  and  others,  very  rare,  and  its  diagnosis  is  only  possi- 
ble in  the  later  stages.  In  every  case  of  tuberculosis  of  the  breast  the 
entire  mamma,  with  the  corresponding  axillary  lymphatic  glands, 
should  he  removed. 

Tuberculosis  of  Bones,  Joints,  and  Tendon  Sheaths.— For  tuberculosis  of 
bones,  joints,  and  tendon  sheaths  the  reader  is  referred  to  the  paragraphs 
upon  these  subjects.  It  need  only  be  stated  here  that  tuberculosis  of 
bones  and  joints  is  very  common,  and  that  the  true  caries  of  bones  and 
joints — the  so-called  fungous  inflammation  of  bones  and  joints — is  with 
few  exceptions  true  tuberculosis.  Tuberculosis  of  bones  and  joints  origi- 
nates ver}"  frequently  as  a  result  of  a  traumatism.  The  tubercular 
joint  inflammations  are,  particularly  in  children,  secondai-y  in  nature, 
as  they  are  most  frequently  due  to  an  extension  of  the  process  from  the 
bones.  The  tuberculosis  of  bones  occurs  chiefly  as  a  tubercular  osteo- 
myelitis, which  very  frequently  leads  to  the  formation  of  large  cold 
abscesses.  Tuberculosis  of  the  tendon  sheaths  manifests  itself  some- 
times as  a  diffuse  fungous  disease  and  sometimes  in  the  form  of  sepa- 
rate nodes. 

Lymph  Glands. — Tuberculosis  of  the  lymph  glands  is  exceedingly 
common,  particularly  in  the  neck.  Areas  of  characteristic  cheesy  de- 
generation and  suppurative  softening  develop  either  primarily  in  con- 
junction with  a  scrofulous  hyperplasia  of  the  glands,  or  secondary  to 
tuberculosis  of  the  lymph  district  in  question.  It  is  of  very  great 
practical  importance  that  this  glandular  tuberculosis  should  receive 
operative  treatment  at  as  early  a  stage  as  possible,  because,  if  the  poi- 
son passes  into  the  circulation,  general  miliary  tuberculosis  may  readily 
follow. 

Lymphatics. — That  tubercular  lymphangitis  is  of  frequent  occur- 
rence can  be  easily  understood  from  the  frequency  of  tubei'culosis  of 
the  lymph  glands. 

Blood-vessels. — The  walls  of  the  arteries,  and  particularly  of  the 
veins,  l)ecome  diseased  both  primarily  from  the  blood  and  secondarily 
from  neighbouring  tubercular  foci. 

Diagnosis. — The  diagnosis  of  tuberculosis  is  rendered  certain  when  it  is 
possible  to  demonstrate  the  presence  of  tubercle  bacilli,  when  inoculation  is 
successful,  and  tbe  microscopic  examination  of  the  tissues  reveals  the  above- 
described  characteristic  structure  of  the  tubercles. 

Prognosis  of  Tuberculosis.— We  have  already  sufficiently  outlined  the 
prognosis  of  tuberculosis.     Even  in  surgical   tuberculosis,  though   radical 


§  83.]  TUBERCULOSIS.  429 

operative  treatment  may  be  adopted,  a  permanent  cure  is  not  so  often  observed 
as  many  enthusiasts  believe  ;  but  the  sooner  the  tubercular  focus  is  removed, 
the  smaller  it  is,  etc.,  so  much  the  more  ground  may  we  have  for  expecting  a 
permanent,  complete  cure.  But,  as  has  been  said,  there  is  always  the  danger 
of  a  fresh  recurrence  of  the  disease  even  years  later.  For  children,  the  prog- 
nosis, in  general,  is  better  than  for  adults  ;  we  often  enough  see  spontaneous 
recovery  take  place  in  them  from  the  most  severe  bone  and  joint  tuberculosis. 
But  we  know,  from  the  statistics  of  Billroth  and  others,  that  individuals 
who  have  suffered  in  their  youth  from  tubercular  disease  of  bone  do  not 
usually  attain  an  advanced  age. 

Treatment  of  Tuberculosis. — The  treatment  of  tiiberculosis  is  partly 
local  and  partly  constitutional.  As  it  is  a  contagious  disease,  healthy 
persons  should  be  protected,  as  far  as  possible,  from  infection.  It  is 
accordingly  the  safest  plan  to  treat  tubercular  patients  in  hosj)itals ; 
those  with  tubercular  disease  of  the  lungs  should  be  treated  in  insti- 
tutions built  for  that  purpose.  The  local  treatment  of  surgical  tuber- 
culosis— e.  g.,  of  the  bones  and  joints — was,  a  few  years  ago,  chiefly 
operative.  At  present  the  treatment  is  much  more  conservative.  The 
operative  treatment  which  used  to  be  employed  so  vigorously  is  in 
part,  and  with  the  best  results,  becoming  supplanted  by  a  more  chemi- 
cal treatment,  consisting  chiefly  in  the  injection  of  drugs  either  into 
the  tubercular  areas,  or  subcutaneously  into  some  healthy  part  of  the 
body,  such  as  the  buttocks,  the  muscles  of  the  thigh,  or  the  skin  of  the 
chest  or  abdomen,  for  the  purpose  of  stimulating  the  metabolism  or 
nutrition.  Particular  mention  should  be  made  of  the  aseptic  injection 
of  sterilised  ten-per-cent.  iodoform  oil  or  iodoform  glycerine — for  ex- 
ample, into  tubercular  joints.  I  have  had  excellent  results  from  this 
treatment,  particularly  in  tuberculosis  of  children  and  young  adults. 
To  avoid  iodoform  intoxication,  it  is  best  to  sterilise  olive  oil  or  gly- 
cerine and  iodoform  separately,  by  heating  them  at  a  temperature  of 
100°  C.  in  the  sterilising  apparatus,  and  then  to  make  with  them  a  ten- 
to  twenty -per-cent.  mixture.  Iodoform,  in  fact,  appears  to  have  a 
direct  antitubercular  action,  as  proved  by  the  experiments  of  Baum- 
garten,  Troje,  and  Tange.  Furthermore,  arsenic,  three  per  cent,  car- 
bolic acid,  tincture  of  iodine,  and  1-5  per  cent,  iodine  iodide  of  potas- 
sium solution  have  been  used  for  intramuscular  and  intra-articular 
injections.  A  solution  of  iodine,  iodide  of  potassium  and  guaiacol  (20.0 
guaiacol,  5.0  iodine,  10.0  iodide  of  potassium,  and  100.0  glycerine) 
may  be  injected  into  the  buttock  or  the  outer  side  of  the  thigh  (Frassi). 
Chloride  of  zinc  (1 :  10-15),  balsam  of  Peru,  calcium  with  phosphoric 
acid,  oil  of  cloves  (1 :  10  olive  oil),  vasogen,  camphor,  naplithol,  copper 
salts,  etc.,  have  been  used  in  a  similar  way.  Lutton  recommends  the 
subcutaneous  injection  of  1  cu.  cm.  of  the  following :  5.0  phosphate  of 


430  INFLAMMATION  AND  INJURIES. 

sodium  in  120  cu.  cm.  of  equal  parts  of  water  and  glycerine,  to  which 
is  added  1.0  acetate  of  cupric  oxide  in  -40.0  water  and  glycerine  equal 
parts.  The  copper  salts  are  said  to  have  a  temporary  inflammatory 
reaction  like  tuberculin  (see  page  431).  Koehler  recommends  the 
external  employment  of  calomel  powder,  Bayer  of  five-per-cent.  iodo- 
form-vasogen,  and  Isnard  of  oil  of  turj)entine  (for  injection  into  listulse 
and  abscesses,  or  as  an  ointment,  with  equal  pai-ts  of  vaseline). 

Arsenic  has  been  recommended  by  Buchner  both  locally  and  inter- 
nally. He  believes  that  this  remedy  greatly  increases  the  powers  of 
resistance  of  the  body,  or  rather  of  the  cells.  P.  Bi-uns  and  others 
have  obtained  no  satisfactory  results  from  the  injection  of  Kolischer's 
phosphate-of-lime  solution  (calc.  phosphor,  ueutr.  5.0,  aq.  dest.  50.0, 
acid,  phosphor,  q.  s.  ad.  solut.  perfect,  filtra,  adde  acid,  phosphor,  dil. 
0.6,  aq.  destil.  q.  s.  adde  100.0,  and  inject  about  10  to  12  to  24  cu.  cm.). 
Similar  unsatisfactory  results  were  obtained  with  Kolischer's  lime- 
gauze  packing.  The  gauze  is  impregnated  with  the  above  solution 
and  contains  ten  times  its  weight  of  dilute  phosphoric  acid,  Mosetig 
Moorhof  speaks  highly  of  the  subcutaneous  injection  of  about  3.0  teu- 
krin  (extractum  teucrii,  scordii  depurat.)  into  the  immediate  vicinity  of 
the  diseased  area ;  given  internally  (0.5  in  gelatine  capsules)  it  stimu- 
lates the  appetite.  Landerer  recommends  the  local  and  particularly 
the  intravenous  injection  of  the  following  cinnamic-acid  emulsion,  which 
must  first  be  rendered  alkaline  :  Acid,  cinamylici  5.0,  ol.  amygdal. 
10.0,  vitelli  ovi  unius,  sol.  natr.  chlor.  (0.7  per  cent.)  q.  s.  ut.  f.  emuls. 
100.0.  Landerer  has  been  using  of  late  two  derivatives  of  cinnamic 
acid,  betol,  or  cinnamate  of  sodium  and  betokresol.  The  cinnamic 
acid  or  its  derivatives,  when  brought  into  the  circulation,  act  only  upon 
vascular  tissues ;  they  have  a  strong  chemotaxic  action,  cause  leucocy- 
tosis,  and  excite  an  artificial  inflammation  in  the  vicinity  of  the  tuber- 
cular focus,  with  encapsulation  of  the  tubercles  and  death  of  the  bacilli 
(Landerer,  Richter). 

A.  Bier  has  obtained  remarkable  success  in  tuberculosis  of  the 
extremities  by  employing  permanent  congestive  hyperaemia,  brought 
about  by  the  application  of  a  rubber  tourniquet  on  the  proximal  side 
of  the  tubercular  disease.  This  method  of  treatment  was  suggested  to 
Bier  by  the  well-known  fact  that  the  congested  lung  is  immune  from 
tuberculosis.  Bier's  passive  congestion  has  been  employed  a  good 
deal  by  Mikulicz,  Zeller,  the  author,  and  others,  and  in  part  with  good 
success.  It  is  a  good  plan  to  use  only  slight  constriction  at  the  out- 
set, to  let  it  act  for  an  hour  at  a  time,  and  to  change  the  place  of  applica- 
tion. Iodoform  is  used  locally  at  the  same  time.  It  sometimes  hap- 
pens that  the  local  process  is  made  worse  by  this  treatment,  and  the 


§83.]  -  TUBERCULOSIS.  431 

latter  has  to  be  given  up.  As  tubercle  bacilli  are  killed  by  heat, 
Pelicet,  Maurel,  Jeannel,  and  others  recommend  after  operation  the 
use  of  dry  or  moist  heat  (thermo-cauterj,  boiling  salt  water).  This 
probably  explains  the  excellent  results  from  ignipuncture  with  the 
thermo-cautery  or  galvano-cautery.  In  other  respects  the  local  treat- 
ment of  tuberculosis  depends  upon  the  part  of  the  body  that  is  dis- 
eased (see  Regional  Surgery).  Tubercular  joints  are  immobilised  by 
splints  (see  Tuberculosis  of  Joints).  The  operative  treatment  of  tuber- 
culosis varies.  It  consists  in  excision  of  the  diseased  area,  ignipunc- 
ture, scraping  with  a  Yolkmann  spoon,  synovectomy,  resection  of  the 
joint,  etc.  In  extreme  cases  the  patient  may  be  saved  by  amputation. 
Operative  treatment  should  be  combined  when  possible  with  medical 
and  general  treatment. 

Iodine,  arsenic,  creosote,  guaiacol,  cod-liver  oil,  and  lactic  acid  are 
the  most  common  internal  remedies.  The  treatment  of  the  general 
condition  of  the  patient  is  very  important,  and  the  course  of  tubercu- 
losis is  influenced  very  markedly  by  good  food  and  good  air  and  by  a 
strengthening  mode  of  life  thoroughly  carried  out.  It  is  also  a  good 
plan  to  employ  baths,  sea  bathing,  sea  voyages,  yearly  sojourns  in 
southern  climates  (Egypt,  Madeira,  Sicily),  and  to  try  high  health 
resorts  (Davos),  etc.  For  prophylactic  reasons,  individuals  with  a 
predisposition  to  tubercular  disease,  or  scrofulous  patients,  should  be 
built  up  by  a  tonic  treatment  and  kept  from  associating  with  those 
"who  actually  have  the  disease. 

Treatment  of  Tuberculosis  with  Koch's  Tuberculin.— The  treatment  of 
tuberculosis  with  Koch's  tuberculin,  a  metabolic  product  of  the  tubercle 
bacilli,  is  of  great  scientific  interest.  It  is  founded  upon  the  idea  of  combat- 
ing the  tubercle  bacilli  and  the  poisonous  products  of  their  metabolism  by 
corresponding  protective  substances  (antitoxines).  We  know,  in  fact,  that 
the  bacterial  toxines  give  rise  to  the  formation  of  antitoxines  which  develop 
their  protective  and  curative  action  chiefly  in  the  blood  serum  of  the  body. 
Koch's  tuberculin  is,  according  to  the  statements  of  the  discoverer,  a  glycerine 
extract  from  pure  cultures  of  tubercle  bacilli,  a  brownish-red  fluid  which 
contains,  in  addition  to  the  active  principle,  a  toxalbumen,  indifferent  col- 
ouring matters,  salts,  and  extractives.  In  animals  (guinea-pigs)  Koch  has 
obtained  very  satisfactory  results  with  tuberculin ;  he  has  cured  tubercular 
guinea-pigs,  and  has  made  others  unsusceptible  to  inoculation  with  tubercle 
bacilli.  In  animals  the  tubercle  foci  are  cast  off  in  a  state  of  necrosis  after 
the  subcutaneous  injection  of  tuberculin. 

The  observations  which  have  been  made  upon  the  use  of  tuberculin  for 
tuberculosis  in  man  have  not  been  as  satisfactory  as  in  guinea-pigs.  After 
its  subcutaneous  injection  in  tubercular  individuals  there  generally  occurs 
within  about  four  to  six  houi's  a  typical  local  and  constitutional  reaction 
which  is  best  illustrated  in  tuberculosis  of  the  skin,  or  lupus.     The  local  his- 


432  INFLAMMATION  AND  INJURIES. 

tological  changes  following  the  injection  of  tuberculin  have  been  described 
by  many  authors.  These  changes  consist  in  a  very  active  inflammation  in 
the  parts  surrounding  the  tubercular  focus  ;  the  tubercle  itself  and  the  bacilli 
are  not  directly  attacked.  In  consequence  of  the  inflammation  of  the  parts 
surrounding  the  tubercular  focus  the  latter  may  be  cast  olf  xuuler  suitable 
conditions,  but  the  typical  necrotic  destruction  of  tbe  tubercular  focus  ob- 
served by  Koch  in  animals  following  the  action  of  the  tuberculin  does  not 
appear  to  take  place,  as  a  rule,  in  man.  .  In  consequence  of  this  inflamma- 
tion of  the  surrounding  parts  the  tubercular  focus  in  lupus,  for  example,  be- 
comes very  much  swollen,  a  tubercular  joint  becomes  extremelj'  painful,  etc. 
Tlie  constitutional  effect  of  tuberculin  observed  even  in  healthy  people  after 
the  administration  of  very  large  doses  consists  in  fever  and  the  other  well- 
known  febrile  constitutional  manifestations,  which  may  assume  a  threaten- 
ing character.  I  have  frequently  observed  a  rise  of  temperature  to  41°  C. 
(105.8°  F.)  and  higher,  and  a  pulse  of  180  to  200.  Examination  of  the  blood 
reveals  a  tempoi"ary  acute  leucocytosis  in  which  all  forms  of  the  white  blood- 
corpuscles  are  involved.  In  consequence  of  this  characteristic  effect  of  the 
tuberculin  upon  the  tubercular  focus  the  remedy  has  great  diagnostic  value  ;. 
only  in  exceptional  cases  does  the  typical  reaction  fail,  as  it  did,  for  instance, 
in  a  case  coming  under  my  observation  and  subsequently  operated  ujjon,  in 
which  there  was  tuberculosis  of  the  testicle  and  kidney.  The  typical  reac- 
tion is  occasionally  observed  even  in  people  seemingly  healthy,  and  then 
usually  means  a  latent  tuberculosis.  In  the  case  of  an  appai*ently  healthy 
medical  student,  I  observed,  after  subcutaneous  injection  of  the  tuberculin, 
a  marked  swelling  of  the  cervical  lymphatic  glands  and  high  fever;  the 
cause  of  this  proved  to  be  an  anatomical  tubercle  on  the  chin,  microscopical 
examination  of  which  after  extirpation  revealed  typical  tubercles. 

There  are  numerous  reports  upon  the  tuberculin  treatment,  particularly 
of  lupus,  but  permanent  cures  have  only  been  obtained  in  very  rare  instances, 
and  not  infrequently  the  tubercular  process  has  been  made  worse.  Unfor- 
tunately the  remedy  has  not  always  been  used  in  properly  selected  cases> 
At  present  tuberculin  is  scarcely  employed  at  all  by  surgeons.  Though 
Robert  Koch  may  not  have  discovered  the  means  of  curing  tuberculosis  in 
man,  he  is  perhaps  upon  the  right  road  to  find  a  valuable  means  of  assistance 
in  the  treatment  of  tuberculosis,  particularly  in  its  early  stages.  The  condi- 
tions for  rendering  it  possible  to  cure  surgical  tuberculosis  are  most  favour- 
able in  those  cases  where  the  tuberculin  ti'eatment  can  be  properly  combined 
with  the  operative. 

As  to  the  technique  of  the  method,  I  may  say  that  I  employ  small  doses 
and  not  too  frequent  injections,  preferably  under  the  skin  of  the  back.  I 
begin  without  exception  with  one  milligramme  of  tuberculin  for  adults  and 
half  a  milligramme  for  children,  once  or  twice  a  week,  gradually  increasing 
the  dose  to  0.01  to  0.10  gramme.  I  do  not  use  large  doses — for  example,  0.20 
to  0.50  gramme  or  more.  By  the  use  of  small  doses  once  or  twice  a  week  the 
marked  loss  of  weight,  occurring  so  easily,  is  prevented,  as  are  also  the 
harmful  constitutional  symptoms.  I  have  used  the  tuberculin  in  a  great 
number  of  cases  of  surgical  tuberculosis,  and  in  some  of  them  I  have  ob- 
served remarkable  improvement,  but  no  cures  either  in  lupus  or  in  any  other 
tuberculosis  of  soft  parts,  bones,  or  joints.     I  am  soi'ry  to  say  that  the  im- 


§83.]  TUBERCULOSIS.  433 

provements  were  only  temporary  in  their  nature,  and  many  cases  were  even 
made  worse. 

The  question  whether  tuberculin  may  occasionally  favour  the  origin  of 
a  general  miliary  tuberculosis — that  is,  whether  tuberculosis  may  be  made 
general  throughout  the  body  by  using  the  remedy — cannot  be  answered  with 
certainty,  but  the  possibility  of  this  must  be  admitted  (Virchow). 

Klebs's  Tuberculocidin. — Klebshas  separated  from  the  curative  substances 
in  Koch's  tuberculin  those  which  are  noxious  (which  produce  the  necrosis) 
by  precipitation  with  platinum  chloride  and  phosphortungstic  acid  and  by 
the  addition  of  alcohol  to  the  residue.  The  medicinal  substance  thus  ob- 
tained, tuberculocidin,  which  belongs  to  the  peptone  group,  has  been  found 
by  Klebs  to  be  of  therapeutic  value. 

Antitubercular  Serum. — The  serum  of  animals  made  immune  to  tuber- 
culosis seems  to  have  in  part  similar  properties  to  tuberculin.  Maragliano 
inoculated  dogs,  asses,  and  horses  with  strong  toxines  of  the  tubercle  bacillus, 
and  employed  with  success  the  serum  of  these  animals  for  tuberculosis  in 
man.  It  is  to  be  hoped  that  the  time  is  not  far  distant  when  we  siiall  possess 
an  effective  antitubercular  serum  which  can  be  injected  subcutaneously  in 
tubercular  subjects  in  the  sarne  way  as  the  antidiphtheritic  serum. 

Cautbaridate  of  Potassium. — Liebreich  recommended  the  subcutaneous 
injection  of  the  cantharidate  of  potassium  (up  to  sixty  grammes)  ;  its  action 
is  the  same  as  that  of  tuberculin.  B.  Frankel,  Heymann,  and  Landgraf 
likewise  obtained  satisfactory  results. 

In  this  connection  a  brief  description  should  be  given  of  the  nature 
and  treatment  of  scrofula. 

Scrofula. — By  scrofula  (from  scrofa,  hog)  is  understood  a  constitutional 
anomaly  without  anatomical  changes  that  are  capable  of  being  positively 
demonstrated.  It  is  characterised  by  a  striking  weakness  of  the  tissues,  or 
rather  of  the  cells,  rendering  them  incapable  of  withstanding  injurious  influ- 
ences from  without.  Consequently  we  observe  that  scrofulous  individuals, 
as  a  result  of  the  slightest  external  violence,  suffer  from  inflammations  of 
every  description,  which  may  involve  the  skin,  mucous  membranes,  or  lym- 
phatic glands.  Scrofulous  people,  as  we  have  remarked  before,  possess  a  pro- 
nounced predisposition  to  tuberculosis — that  is,  the  scrofulous  constitutional 
anomaly,  with  its  local  acute  and  chronic  foci  of  inflammation,  is  an  excellent 
soil  for  the  tubercle  bacillus.  The  relationship  between  scrofula  and  tuber- 
culosis has  been  very  frequently  discussed,  and  since  the  discovery  of  the 
tubercle  bacillus  the  connection  between  them  has  become  better  understood. 
We  now  assume  that  scrofula  has  nothing  to  do  with  true  tuberculosis  ;  it  is 
rather  a  constitutional  anomaly  by  which  infection  with  the  Bacillus  tuber- 
culosus  is  favoured. 

If  we  have  to  deal  with  a  cheesy  or  suppurative  lymphadenitis,  which  is 
so  often  observed  in  scrofula,  the  decision  as  to  whether  we  have  to  deal  with 
tuberculosis  or  not  is  made  solely  upon  the  demonstration  of  tubercle  bacilli. 
The  same  thing  holds  true  of  the  so-called  cold,  scrofulous  abscess  in  the  soft 
parts,  and  the  chronic  inflammations  of  bones  and  soft  parts.  I  am  of  the 
opinion  that  a  pseudo-tuberculosis  occurs  in  scrofulous  individuals  which  is 
analogous  to  that  observed  in  animals,  which  was  described  by  Eberth,  Ma- 


434  INFLAMMATION   AND   INJURIES. 

lassez,  and  Vignal  (page  420) ;  it  runs  a  course  similar  to  true  tuberculosis, 
thoug-li  caused  by  other  micro-organisms  (cocci,  bacilli),  and  not  by  the  Bacil- 
lus fnberculosus  Kochii. 

The  scrofulous  diathesis  is  either  congenital  or  acquired,  as  a  result  of 
unfavourable  external  hygienic  conditions,  a  lack  of  proper  nourishment, 
living  in  bad  surroundings,  etc.  The  most  important  marks  of  scrofula 
consist,  in  the  first  place,  of  a  series  of  manifestations  which  are  usually 
grouped  together  under  the  name  of  habitus  scrofulosiis.  I'or  convenience 
we  distinguish  two  forms  of  scrofula :  the  irritable  and  the  torpid  form. 
Scrofulous  individuals  have  in  general  a  thin,  delicate,  transparent  skin  ; 
they  are  more  apt  to  be  blond  than  dark,  and  are  of  a  very  excitable 
temperament  (irritable  form).  In  the  torpid  form  of  scrofula  the  skin  is 
more  puffed,  the  subcutaneous  fat  remarkably  vrell  developed,  and  the  ab- 
domen protruding.  But  all  these  manifestations  are  observed  without  scrof- 
ula, and  the  latter  fii-st  becomes  evident  to  the  eye  when  local  inflamma- 
torj'  manifestations  make  their  appearance,  particularly  inflammations  of 
the  skin,  mucous  membranes,  and  glands.  Of  these  the  most  constant  are  : 
Eczemas  of  every  description  which  are  so  common  ;  the  catarrh  of  the  throat, 
bronchi,  stomach,  and  intestines ;  the  pronounced  conjunctivitis,  blepharo- 
adenitis,  and  keratitis.  The  lymph  glands  are  usually  swollen  and  enlarged, 
with  or  without  simultaneous  cheesy  degeneration.  This  is  particularly  the 
case  with  the  lymph  glands  of  the  neck  and  submaxillary  region,  where  great 
masses  of  enlarged  lymph  glands  may  exist.  In  this  way  the  neck  becomes 
very  plump,  and  merges  gradually  into  the  head  and  trunk,  as  in  pigs.  The 
old-fashioned  term  of  scrofula  was  derived  from  this  comparison.  In  this 
caseous  lymphadenitis  the  transitions  to  true  tuberculosis  are  very  common. 

Treatment  of  Scrofula. — The  treatment  of  scrofula  must  be  directed  first 
and  chiefly  towards  overcoming  the  existing  constitutional  anomaly,  particu- 
larly by  the  enforcement  of  prosier  hygienic  rules — that  is,  by  taking  care  to 
supply  good  nourishment,  air,  and  light ;  by  proper  exercise  in  fresh  air  ;  by 
muscular  exertion  (gymnastics,  swimming),  etc.  A  residence  at  the  seaside 
is  particularly  to  be  recommended  in  scrofula.  This  does  not  have  a  specific 
effect ;  it  is  only  an  adjuvant  in  the  cure,  exciting  the  appetite  of  the  patient 
and  thus  improving  his  nutrition.  The  diligent  use  of  salt  baths  (up  to  three 
per  cent.)  has  a  good  reputation  in  the  treatment  of  scrofula ;  they  should  be 
employed  daily,  or,  in  the  case  of  weak  individuals,  two  or  three  times  a  week 
and  for  ten  to  thirty  minutes.  Kreuznach,  Nauheim,  Oeynhausen,  Reichen- 
hall,  and  Heilbronn  have  the  best  reputation  among  the  bathing  resorts. 
They  ai^e  particularly  recommended  on  account  of  the  iodine  and  bromine 
contained  in  the  watei's.  The  water  is  used  to  drink  as  well  as  to  bathe  in. 
The  administration  of  cod-liver  oil,  fifteen  to  twenty  to  thirty  grammes  a 
day,  particularly  in  winter,  is  likewise  recommended.  Cod-liver  oil  is  an 
easily  digestible  fat  of  dietetic  importance.  Furthermore,  scrofulous  subjects 
should  be  cautiously  toughened  by  degrees,  to  render  them  more  capable 
of  withstanding  the  frequent  catarrhs  of  the  mucous  membranes.  Every 
scrofulous  local  disease  should  receive  proper  treatment.  In  the  matter  of 
prophylaxis,  too  much  emphasis  cannot  be  laid  upon  the  importance  of  pro- 
tecting scrofulous  children  from  contagion  with  tuberculosis,  and  from  in- 
tercourse with  those  who  have  the  latter  disease. 


§  84.]  SYPHILIS.  435 

§  84.  Syphilis  {Lues). — By  syphilis  we  understand  a  chronic  infec- 
tious disease  which,  according  to  recent  investigations,  is  most  prob- 
ably caused,  like  tuberculosis,  by  a  characteristic  fungus.  By  the  trans- 
ference of  bacilli  to  apes,  Klebs  brought  about  inflammations  some  of 
which  ran  a  course  similar  to  the  inflammation  in  syphilis,  others  to 
that  in  tuberculosis.  Lustgarten,  under  Weigert's  guidance,  by  using 
a  special  method,  succeeded  in  demonstrating  in  tissues  which  had 
undergone  syphilitic  changes,  and  in  the  secretion  from  syphilitic  ulcers, 
a  particular  species  of  bacillus  (Figs,  339,  340)  which  is  morphologic- 
ally similar  to  the  tubercle  bacillus,  but  differs  from  it  in  shape, 
more  frequently  occurring  in  a  slightly  curved  form,  with  knob-shaped 
enlargements  at  its  ends.  It  also  differs  in  its  micro-chemical  behav- 
iour.    While  the  tubercle  and  lepra  bacilli,  which  are  also  brought  to 


^  m. 


^%M 


;39.— Wanderinj 

bacilli.     X  1,050  (Lustgarten)."  bacilli.  '  x  1,050  (Lustgarten). 


„.-   ^.,  -*-  YiQ.  340. — Dry  preparation  of  pus  taken 

Fig.  339. — Wandering  cells  with  syphilis  from  a  syphilitic  sclerosis  with  syphilis 


view  by  Lustgarten's  method,  are  not  decolorised  by  hydrochloric  or 
nitric  acids  (or  only  after  being  subjected  to  them  for  a  long  time),  the 
syphilis  bacilli  rapidly  part  with  their  stain  under  the  influence  of  these 
acids.  The  syphilis  bacteria,  as  yet,  are  not  distinguished  by  any  other 
absolutely  characteristic  staining  reaction.  Lustgarten  never  found  the 
bacilli  free  in  the  tissue,  but  always  inside  large  oval  or  polygonal  cells, 
chiefly  wandering  cells  (Fig.  339).  They  occur  here  either  singly  or  in 
groups  of  two  to  eight.  The  bacilli  can  usually  be  detected  only  in 
small  numbers ;  they  are  found  most  commonly  in  cover-glass  prepa- 
rations (Fig.  340),  less  often  in  sections. 

Method  of  Staining  Syphilis  Bacilli.— The  syphilis  bacilli  are  stained  by 
Lustgarten  as  follows  :  The  thinnest  possible  sections  are  treated  with  aniline- 
gentian  violet  for  twelve  to  twenty-four  hours,  at  the  ordinary  room  tem- 
perature, then  for  two  hours  longer  at  a  temperature  of  40°  C  in  the  incu- 
bator; washed  in  absolute  alcoliol  for  several  minutes,  then  for  about  ten 
seconds  in  a  one  and-a-half-per-cent.  solution  of  permanganate  of  potassium, 
and  for  one  to  two  seconds  in  an  aqueous  solution  of  sulphuric  acid,  and 
then  washed  in  distilled  water.     The  latter  three  steps  should  be  repeated 


436  INFLAMMATION  AND  INJURIES. 

many  times  until  the  section  appears  conipletelj^  colourless,  then  it  is  ti'eated 
with  alcohol,  oil  of  cloves,  and  xylol-Canada  balsam.  Cover-glass  prepara- 
tions are  treated  in  a  similar  way,  except  that,  after  staining  in  gentian  vio- 
let, distilled  water  is  used  instead  of  absolute  alcohol,  and  the  separate  steps 
in  the  process  follow  one  another  more  rapidly.  De  Giacomi  stains  the  prep- 
arations in  Ehrlich's  aniline-water-fuchsin  solution,  and  then  treats  them 
with  a  chloride-of-iron  solution. 

The  siffnificanee  of  Lusto-arten's  bacilli  has  been  rendered  somewhat 
doubtful  by  Alvarez,  Tavel,  Matterstock,  and  others.  These  authors 
have  found  in  the  preputial  smegma,  and  in  the  secretion  between  the 
labia  majora  and  minora  and  about  the  anus,  bacilli  having  the  same 
appearance  and  the  same  staining  reaction  as  Lustgarten's  syphilis 
bacilli.  At  all  events,  the  etiological  importance  of  Lustgarten's  bacilli 
must  be  tested  by  further  investigation,  and  the  question  must  remain 
unsettled  as  long  as  it  continues  to  be  impossible  to  artificially  cultivate 
the  syphilis  bacteria  and  to  inoculate  them  successfully  upon  suscepti- 
ble animals.  By  far  the  greater  number  of  physicians  are  at  present 
of  the  opinion  that  syphilis  is  caused  by  a  specific  micro-organism,  but 
t]iat  this  micro-organism  has  not  yet  been  discovered. 

Transmission  of  Syphilis  to  Animals.  —Disse  and  Taguchi  claim  to  have 
found  in  the  blood  of  syphilitic  subjects,  partly  by  microscopical  examina- 
tion and  partly  by  Koch's  culture  methods,  spore-forming  bacilli,  by  inocula- 
tion of  which  upon  animals  they  have  excited  in  the  latter  syphilitic  disease. 
This  statement  must  be  regarded  with  suspicion,  as  should  be  the  analogous 
reports  of  Martineau  and  Hamonic  upon  positive  ti'ansmission  experiments, 
since  it  has  hitherto  been  the  common  experience  to  find  that  the  syphilitic 
poison  cannot  be  successfully  inoculated  upon  animals.  Furthermore,  the 
experiments  of  Klebs  relating  to  inoculation  upon  apes,  as  stated  before, 
yielded  doubtful  results. 

Origin  of  Syphilis. — Syphilis  originates  by  the  poison  being  directly 
transferred  from  one  individual  to  another,  particularly  during  coitus ; 
less  frequently  it  is  extragenital  in  origin.  It  is  sometimes  hereditary. 
The  broad  condylomata  (moist  papules,  see  page  440)  are  the  most  fre- 
quent source  of  the  contagion.  It  is  doubtful  whether  the  contents  of 
the  gummata,  or  in  general  of  the  local  formations  of  the  tertiary  period 
of  syphilis,  are  infectious.  The  transference  of  syphilis  is  only  possil)le 
when  the  poison  is  inoculated  in  an  injured  spot,  in  some  interruption 
of  continuity — for  instance,  of  the  most  superficial  layer  of  the  skin, 
which  may  often  be  very  insignificant.  The  syphilitic  poison  is  some- 
times inoculated  into  two  different  parts  of  the  body  at  the  same  time, 
so  that  two  primary  lesions  are  formed.  The  syphilis  poison  reproduces 
itself  apparently  only  in  the  human  organism,  since  indisputable  inocu- 
lations in  animals,  as  stated  above,  have  not  hitherto  been  observed. 


§84.]  SYPHILIS.  43Y 

Extragenital  Modes  of  Infection.— The  statistical  data  upon  the  freqiiencj 
of  the  propagation  of  syphilis  hy  extragenital  infection  vary  greatly.  Ac- 
cording to  Miinchheimer,  the  number  of  cases  of  extragenital  primary  lesions 
published  up  to  1897  was  10,265,  their  frequency  being  on  the  average  six  to 
seven  per  cent.  Generally  speaking,  extragenital  infection  is  more  common 
in  women  than  in  men,  but  this  may  be  only  apiDarently  so,  as  primary 
lesions  on  the  female  genitals  are  often  overlooked.  According  to  Jullien 
and  Fournier,  an  extragenital  origin  of  syphilis  in  men  occurs  in  from  five 
to  six  per  cent,  of  the  cases ;  in  women,  on  the  other  hand,  in  from  twenty- 
five  to  twenty-six  per  cent.  Krefting  obtained  similar  figures  on  the  basis  of 
539  cases  (4.3  per  cent,  in  men  against  32.8  per  cent,  in  women).  According 
to  Hahn,  of  6,368  male  syphilitics,  only  131  (2.05  per  cent.),  and  of  7,141 
females,  159  (2.22  per  cent.)  showed  an  extragenital  mode  of  infection. 
Mracek  (Siegmund's  clinic)  gives  an  extragenital  infection  of  one  per  cent, 
for  men  and  foui'teen  per  cent,  for  women. 

The  different  portions  of  the  body  which  are  the  seat  of  the  primaiy 
extragenital  infection  of  syphilis  are,  in  the  order  of  frequency,  as  follows : 
Lips,  anus,  finger,  tongue,  breast,  abdomen,  leg,  palate.  The  comparative 
frequency  of  extragenital  infection  about  the  mouth  is  caused  by  kissing,  by 
drinking  utensils,  pipe-tips,  cigar-ends,  tooth-picks,  etc.  Finger  infection  is 
particularly  common  in  physicians  and  midwives.  Syphilis  can  also  be 
transferred  by  the  primary  lesion  on  the  hands  of  physicians  and  midwives 
to  their  patients  (Neisser).  It  is  not  infrequently  transferred  by  infected 
instruments — for  exam^Dle,  in  dental  operations,  in  shaving,  etc.  It  is  un- 
doubtedly possible  that  syphilis  may  be  transmitted  by  vaccination.  Occa- 
sionally an  entire  family  may  become  infected  by  a  syphilitic  nurse.  The 
modes  of  extragenital  infection  are  very  varied ;  Bulkley  has  collected  over 
a  hundred.  I  doubt  the  assertion  that  syphilis  caused  by  extragenital  infec- 
tion runs  a  more  severe  course  than  that  due  to  genital  infection,  but  it  is 
true  that  the  extragenital  variety  is  usually  recognised  too  late.  This 
explains  the  family  epidemics  and  other  extensive  syphilis  epidemics. 

Inheritance  of  Sjrphilis. — The  question  as  to  whether  syphilis  can  be 
inherited  is  of  great  practical  import.  As  a  matter  of  fact,  it  has  been 
proved  that  it  can  be.  The  inheritance  of  syphilis  is  possible  in  two  differ- 
ent ways :  by  the  poison  attaching  itself  to  the  spermatozoon  or  the  ovum, 
or  by  the  healthy  foetus  becoming  infected  from  the  blood  of  the  mother 
(intra-uterine  infection).  It  has  been  proved  that  syphilis  may  be  inherited 
in  the  first  of  these  two  ways,  and  it  appears  to  proceed  from  the  father 
more  frequently  than  from  the  mother.  The  transmission  of  syphilis  by 
the  father  alone — that  is,  by  the  spermatozoa — has  been  proved  by  the  fact 
observed  by  many  authors,  such  as  Hebra,  Gerhardt,  Weil,  etc..  that  a  non- 
syphilitic  mother  can  give  birth  to  a  syphilitic  child.  The  intra-uterine 
infection,  on  the  contrary,  has  not  hitherto  been  demonstrated ;  but  it  is 
theoretically  conceivable  and  possible  for  a  woman,  who  becomes  syi^hilitic 
during  her  pregnancy,  to  infect  her  child  by  means  of  the  blood-channels. 
But  we  should  not  omit  to  say  that  Barensprung  and  Kassowitz,  particu- 
larly, have  vigorously  contested  the  possibility  of  this  intra-uterine  infec- 
tion, on  the  ground  that  it  would  be  impossible  for  the  syphilis  poison 
to  pass  through  the  placenta.     As  a  matter  of  fact,  it  frequently  happens 


438  INFLAMMATION   AND   INJURIES. 

that  womeu  -with  recent  syphilis  give  birth  to  children  who  are  healthy  and 
remain  so. 

Still  another  question  is  of  great  practical  importance.  Can  a  syphilitic 
foetus,  originating,  for  instance,  from  syphilitic  spermatozoa,  infect  its 
healthy  mother  ?  Such  a.>  occurrence  is  contested,  like  the  above-men- 
tioned intra-uterine  infection  of  the  foetus  from  the  mother,  and  as  a  matter 
of  fact  it  has  not  as  yet  been  proved. 

The  recent  investigations  of  Birch-Hirschfeld  in  regard  to  the  question 
of  foetal  infection  are  exceedingly  interesting  (see  also  page  425).  As  he  has 
maintained,  the  placenta,  under  normal  conditions,  is  impervious  for  finely 
divided  foreign  bodies  and  micro-organisms,  but  the  filter  may  become  per- 
vious by  pathological  processes,  or  by  the  lodgment  in  it  of  micro-organisms, 
so  that  then  bacteria  in  particular,  such  as  tubercle  and  anthrax  bacilli,  pass 
over  from  the  maternal  to  the  foetal  circulation,  or  rather  grow  through 
the  tissues. 

In  fresh  syphilis  of  the  parents  the  foetus  usually  dies  before  the  end  of 
pregnancy.  In  attenuated  late  syphilis  of  the  parents  the  child  is  more  apt 
to  be  carried  to  full  term  and  then  born  with  manifest  signs  of  syphilis,  or 
the  syphilis  appears  soon  after  birth.  Occasionally  hereditary  syphilis  makes 
its  fii'st  appearance  veiy  late,  as  Fournier  in  particular  has  recently  shown. 
Such  cases  of  syphilis  hereditaria  tarda  are  not  infrequently  confused  with 
scrofula  or  tuberculosis.  When  the  correct  diagnosis  is  made  in  such  cases, 
remarkable  success  can  be  obtained  by  the  adoption  of  antisyphilitic  treat- 
ment. In  general  the  phenomena  of  congenital  syphilis  are  the  same  as  in 
the  acquired.  There  are  observed  the  same  tertiary  manifestations,  with 
serious  pathological  changes  in  the  skin,  the  viscera,  and  the  bones  (Parrot, 
Lannelongue).  It  is  important  to  note  that  deafness  or  difficulty  in  hearing 
occur  rather  frequently  in  hereditary  syphilis.  Syphilis  of  the  father  is  less 
dangei'ous  for  the  children  than  that  of  the  mother ;  syphilis  of  both  parents 
is  the  most  dangerous.  The  mortality  among  childi'en  with  syphilitic  mothers 
who  have  not  been  treated  is,  according  to  Etienne,  enormously  high : 
seventy-six  j)er  cent,  die  at  birth  or  are  stillborn,  and  over  ninety-five  per 
cent,  of  the  few  that  are  born  alive  die  very  young.  Antisyphilitic  treatment 
of  the  syphilitic  mother  during  pregnancy  reduces  the  mortality  to  eleven 
to  sixteen  per  cent.  (Etienne).  The  mortality  and  frequency  of  hereditary 
syphilis  is  particularly  marked  in  the  children  of  prostitutes  f^^erner). 

When  can  a  Syphilitic  Individual  Marry  ?— The  question  as  to  the  dura- 
tion of  the  contagious  period  of  syphilis  has  been  answered  very  differently. 
In  my  opinion  it  is  impossible  to  fix  the  length  of  this  period,  and  the  ques- 
tion as  to  when  a  syphilitic  individual  can  be  given  permission  to  marry  is 
difficult  to  answer.  In  the  gi'eat  majority  of  cases  the  contagiousnef^s  is  lost 
after  three  to  four  years  of  proper  treatment.  But  it  has  frequently  hap- 
pened that  wives  have  been  infected  by  secondary  syphilides  six  to  ten  to 
fifteen  and  even  seventeen  years  after  the  primary  lesion  (Feulard).  The 
predisposition  of  the  infected  individual  is  of  great  importance.  Irritations 
of  the  mucous  membrane — e.  g.,  of  the  mouth  from  smoking — predispose 
to  the  formation  of  mucous  patches  which  are  very  infectious.  For  this 
reason  it  is  well  to  be  cautious  in  granting  syphilitics,  who  are  heavy 
smokers,  permission  to  marry  (Feulard). 


84] 


SYPHILIS. 


439 


Symptoms  and  Course  of  Syphilis. — If  we  grant  that  syphilis  is  an 
infectious  bacterial  disease,  its  manifestations  will  be  caused  partly  by 
the  micro-organisms  themselves  and  partly  by  the  toxines  which  they 
form.  Syphilis  begins  with  the  appearance  at  the  point  of  infec- 
tion of  the  so-called  syphilitic  initial  sclerosis,  or  Hunter's  indura- 
tion, or  the  hard  chancre.  This  specific  formation  is  usually  first 
capable  of  demonstration  two  to  four  weeks  after  infection,  though 
sometimes  sooner.  The  primary  syphilitic  initial  sclerosis  is  genei-allj 
a  hard  (indurated),  painless  (indolent)  nodule,  which  gradually  increases 
in  circumference  and  then  most  commonly  changes  into  an  ulcer.  In 
this  way  ulcers  are  formed  with  a  hard,  parchment-like  base,  or  the 
order  is  reversed,  and  a  vesicle  develops  first,  which  ulcerates  and  then 
indurates.  Often  enough  the  syphilitic  initial  infection  is  so  small 
that  it  is  easily  overlooked,  particularly  in  women,  and  the  secondary 
manifestations  occurring  after  a  certain  length  of  time  are  the  first  indi- 
cation that  syphilitic  infection  has  taken  place.  The  primary  lesion 
is,  as  a  rule,  single,  but  multiple  ones 
are  occasionally  observed.     Only  in  ? 

rare  instances  is  the  syphilitic  pri- 
mary infection  complicated  by  pha- 
gedsenic  changes — that  is,  by  spread- 
ing gangrene. 

The  microscopical  examination 
of  the  syphilitic  initial  sclerosis,  or 
of  the  primary  syphilitic  scleroma, 
shows  that  we  have  to  deal  essen- 
tially with  a  collection  of  round  cells, 
epithelioid  cells,  and  occasionally 
giant  cells  (Fig.  341).  These  cells 
break  down  after  a  certain  length  of 
time,  giving  rise  to  an  ulcer ;  finally, 

the  disintegrated  cells  are  absorbed,  and  cicatrisation  occurs.  The  chief 
element  in  the  primary  lesion  consists  in  the  formation  of  a  chronic 
inflammatory  infiltration  of  cells  with  subsequent  cellular  proliferation 
in  the  walls  of  the  lymphatics  and  veins,  with  corresponding  thicken- 
ing of  the  same  (Kieder).  A  similar  proliferation  of  cells  takes  place 
later  in  the  arteries  (syphilitic  endarteritis,  see  page  440). 

Six  to  eight  weeks  after  the  infection,  or  later,  the  constitutional 
manifestations  of  syphilis  make  their  appearance,  and  are  due  to  the 
fact  that  the  poison  has  been  taken  into  the  circulation  from  the 
primary  focus  of  infection  and  carried  through  the  entire  body.  The 
twelfth  day  is  the  earliest  period  at  which  the  outbreak  of  the  consti- 


FiG.  341. — Section  through  a  hard  chancre  : 
a,  round-celled  infiltration  ;  6,  large  mon- 
onuclear cells ;  c,polynuclear  giant  cells. 
Hsematoxylin  staining,     x  300. 


440  INFLAMMATION  AND  INJURIES. 

tutional  inanifestatioiis  has  hitherto  been  observed.  Occasionally  the 
constitutional  symptoms  occur  very  late — for  instance,  in  cases  seen  by 
Giinz  and  Rinecker,  one  hundred  and  thirty  and  one  hundred  and 
fifty -nine  days  resjjectively  after  infection.  Of  the  symptoms  of  syph- 
ilitic constitutional  infection,  the  first  to  occur  is  an  enlargement  of  the 
lymph  glands  in  different  parts  of  the  body  ;  for  example,  in  the 
inguinal  region,  at  the  elbow,  in  the  neck,  etc.  They  can  readily  be 
made  out  by  palpation.  Then  the  skin  and  mucous  membranes  be- 
come diseased.  We  observe  spotted  (macular)  or  nodular  (papular), 
exfoliating  (desquamating)  or  large  tuberous  eruptions  of  the  skin ; 
also  cutaneous  ulcers,  ulcers  on  the  palate,  the  lips,  tongue,  anus,  etc. 
Occasionally  the  spots  upon  the  skin,  particularly  in  women,  have  a 
whitish  character  (leucoderma  syphilitica).  In  conjunction  with  a 
severe  syphilitic  exanthema  there  is  sometimes  observed  a  circum- 
scribed atrophy,  or  thinning  of  the  skin,  in  the  form  of  bluish-coloured 
areas,  in  which  the  cutis  forms  very  small  folds.  Following  the  above- 
mentioned  manifestations  in  the  skin  and  mucous  membranes,  there 
occur  later  syphilitic  diseases  of  the  internal  organs,  particularly  the 
testicle,  liver,  brain,  bones,  joints,  muscles,  and  peripheral  nerves. 
The  cutaneous  eruptions  are  sometimes  accompanied  by  jaundice  and 
enlargement  of  the  liver.  Among  the  bones  most  commonly  affected 
are  those  of  the  skull,  the  tibia,  and  tlie  sternum.  In  the  skull  and  nose, 
as  we  shall  see  in  Regional  Surgery,  there  occur  very  characteristic 
losses  of  substance.  The  syphilitic  diseases  of  the  central  nervous 
system  and  of  the  peripheral  nerves  are  of  great  practical  import- 
ance. Degeneration  of  the  posterior  columns  of  the  cord  (tabes)  is  ob- 
served in  syphilitic  subjects  particularly  (Erb).  The  8y23hilitic  poison 
may  be  deposited  in  all  the  organs  and  in  every  tissue  and  excite  chronic 
inflammator}^  processes  of  various  kinds,  especially  in  the  walls  of  the 
vessels,  in  the  form  of  a  syphilitic  endarteritis,  in  which  there  is  a 
thickening  of  the  wall,  particularly  of  the  intima,  and  a  narrowing,  or 
even  closure,  of  the  lumen.  The  syphilitic  eudartei'itis  and  arterio- 
sclerosis also  give  rise  to  dilatation  (aneurism)  of  the  larger  arteries, 
particularly  the  aorta.  In  other  parts  there  are  produced  by  the  syph- 
ilitic inflammation  either  circumscribed  growths  or  diffuse  inflammatory 
infiltrations,  with  a  tendency  towards  cicatricial  formation.  Among 
the  circumscribed  specific  formations  of  syphilis  should  be  mentioned, 
first  of  all,  the  gumma  (Yirchow),  which  is  also  called  syphiloma  (E. 
Wagner),  and  the  broad  condyloma  {condyloma  latum).  The  syphilom- 
ata,  gummata,  or  gumma  tumours,  so  called  on  account  of  their  char- 
acteristic elastic  property,  are  observed  especially  in  the  testicle,  liver, 
spleen,  meninges,  periosteum,  the  marrow  of  the  bones,  and  occasionally 


§  84.] 


SYPHILIS. 


441 


also  in  the  blood-vessels  (Yirchow,  Baumgarten,  and  Langenbeck).  Thej 
are  either  jelly-like  formations,  with  few  cells,  or  nodes  made  up 
largely  of  cells,  and  more  or  less  like  granulation  tissue,  with  the  single 
•difference  that  the  new 
formation  of  vessels  is 
very  limited.  By  the 
breaking  down  of  the 
gummatous  nodes  ex- 
tensive ulcerations  oc- 
casionally result,  par- 
ticularly in  the  skin. 
The  majority  of  tu- 
mours which  make  their 
appearance  in  the  mus- 
cles are  of  syphilitic 
origin.  The  muscular 
syphiloma  has  a  predi- 
lection for  the  sterno- 
mastoid,  which,  accord- 
ing to  F.  Karewski,  is 
affected  in  one  third  of 
all  the  cases.  In  other 
•cases  the  myositis  syphi- 
litica is  diffuse.  Many  of  the  so-called  "  rheumatic  muscular  thicken- 
ings "  can  be  referred  to  syphilitic  processes  (Braman).  The  broad 
condyloma  is  found  particularly  about  the  vulva  and  the  anus.  It  pre- 
sents itself  in  the  form  of  a  papillary,  moist  induration  of  the  skin  or 
mucous  membranes,  caused  by  serous  ti-ansudation  and  cellular  infil- 
tration of  the  corium  or  mucous  membrane.  The  tendon  sheaths  are 
only  rarely  diseased  in  syphilis.  This  occurs  in  the  early  period  in  the 
form  of  acute  and  subacute,  serous  or  serofibrinous  effusions  {hydroj)s 
tendinum),  or  later  as  a  gummatous  teno-synovitis  with  the  formation 
•of  painless  nodes  (Schuchardt). 

The  syphilitic  diseases  of  joints  (see  also  Diseases  of  Joints)  which 
occur  in  the  later  stages  of  syphilis  are  particularly  interesting.  Ana- 
tomically they  sometimes  take  the  form  of  circumscribed  ulcerations 
or  carious  processes,  fibrillations  of  the  cartilage  with  the  formation  of 
villous  excrescences,  and  sometimes  a  proliferation  of  connective  tis- 
sue or  cicatricial  tissue  in  the  form  of  bands,  or  more  diffuse  growths. 
The  ulcerative  or  carious  processes  are  essentially  due  to  the  gumma- 
tous infiltrations,  and  the  cicatricial  tissue  is  the  final  result  of  inflam- 
mations of  this  sort. 
31 


Fig.  342. — Broad  condylomata  of  the  anus,  periiiEeum,  and 
scrotum  in  a  man  twenty-eight  years  old. 


442  IXFLAMMATlUX   AND   INJURIES. 

Extensive  hreraorrhages  are  observed,  particularly  in  hereditary 
syphilis,  as  the  result  of  local  diseases  of  the  vessels  and  the  parenchyma 
(Mraeek,  syphilis  hcemorrhagica  neonatorum). 

All  these  diverse  manifestations  of  syphilis  which  have  been  so 
briefly  outlined  can  be  divided  into  three  stages. 

The  first  stage  includes  the  incubation  period  of  syphihs — that  is, 
the  formation  of  the  local  syphilitic  sclerosis  or  the  Ilunterian  indura- 
tion at  the  point  of  infection. 

The  second  stage  begins,  some  six  to  eight  weeks  after  the  infec- 
tion, with  the  occurrence  of  the  first  constitutional  manifestations 
(swelling  of  the  lymph  glands,  a  macular,  papular,  or  scaly  eruj^tion  on 
the  skin  and  mucous  membranes),  which  are  accompanied  by  more  or 
less  fever.  The  other  cutaneous  affections  for  the  most  part  appear 
two  to  three — less  often  four  to  six — months  after  the  infection.  Ac- 
cording to  Siegmund,  syphilis  can  be  stamped  out  at  this  stage  by 
proper  treatment  in  about  forty  per  cent,  of  all  cases. 

The  third  stage  is  characterised  by  the  occurrence  in  the  different 
organs  of  gummatous  forms  of  inflammation. 

Still  a  fourth  stage  can  be  added  if  so  desired,  including  the  syphi- 
litic atrophy  and  the  syphilitic  marasmus.  In  general,  the  severe 
form  of  syphilis  passing  through  all  the  different  stages  occurs  when 
the  disease  does  not  receive  proper  care  and  suitable  treatment.  jSTot 
infrequently  cases  are  observed  which  run  a  decidedly  malignant 
course  {syphilis  maligna).  The  term  malignant  syphihs  has  been  un- 
derstood in  very  different  ways.  Two  varieties  can  be  differentiated 
according  to  the  form  of  the  disease,  and  the  situation  of  the  local 
manifestations.  The  really  malignant  form  of  the  disease  is  character- 
ised by  a  severe  acute  course  with  phagedaenic  changes  in  the  primary 
lesion,  multiple  pus  foci,  severe  pustular  eruptions  in  the  skin,  etc, ; 
this  may  be  due,  according  to  Tarnowsky,  to  a  mixed  infection  with 
staphylococcus  or  other  bacteria.  Malignant  syphilis  may  in  other  cases 
be  characterised  by  the  early  appearance  of  tertiary  symptoms,  partic- 
ularly in  the  internal  organs.  The  occurrence  of  this  form  is  said  to 
be  favoured,  in  Russia,  by  chronic  malaria.  Syphilis  can  also  run  a 
malignant  course  by  attacking  vital  organs  at  an  early  period. 

The  Changes  in  the  Blood  in  Syphilis,  according-  to  Bieganski  and  others, 
consist  in  a  marked  leucocytosis  Avhich  is  due  essentially  to  an  increase  in 
the  number  of  the  leucocytes.  According  to  Reiss,  the  red  corpuscles  di- 
minish in  number  but  little  during  the  primary  stage,  but  more  rapidly  after 
the  appearance  of  tbe  constitutional  symptoms,  and  also  during  the  first  part 
of  the  mercurial  ti'eatment :  the  percentage  of  haemoglobin  falls  constantly 
from  the  first  week  of  the  primary  lesion.     Under  the  mercurial  treatment 


§84.]  SYPHILIS.  443 

the  number  of  red  corpuscles  and  the  amount  of  haemoglobin  in  the  blood 
increase  again,  and  the  leucocytosis  becomes  diminished. 

Syphilitic  Albumiimria. — Syphilitic  lesions  of  the  kidney  are  not  fre- 
quent, and  the  albuminuria  that  occurs  in  the  course  of  syphilis  can  be  the 
result  also  of  the  mercurial  ti^eatment  (Welander).  The  syphilitic  albumi- 
nuiia  is  occasionally  observed  at  the  beginning-  of  the  second  stage,  and  is 
usually  completely  and  permanently  cured  by  antisyphilitic  treatment.  A 
second  form  of  syphilitic  albuminuria,  occurring  in  the  later  stages  of  syphi- 
lis, is  more  unfavourable  ;  it  generally  marks  the  beginning  of  a  chronic 
nephintis  (Horteloup). 

Syphilitic  Dental  Deformities.— Hutchinson,  in  particular,  has  directed 
attention  to  the  syphilitic  deformities  of  the  teeth  in  congenital  syphilis. 

Syphilitic  Pseudo-paralyses. —  Syphilitic  pseudo-paralyses  are  observed, 
according  to  Parrot  and  others,  for  the  most  part  in  children  two  to  three 
months  old.  Usually  the  children  are  suddenly  unable  to  move  the  affect- 
ed extremity,  most  frequently  the  upper ;  the  extremity  is  painful,  and  gen- 
erally in  the  region  of  an  epiphysis — the  lower  epiphysis  of  the  humerus,  for 
example — a  diffuse  swelling  and  slight  crepitation  can  be  made  out.  The 
sensibility  and  the  electrical  excitability  of  the  muscles  are  intact.  The  fin- 
gers can  be  moved  a  little.  Generally,  after  a  certain  length  of  time,  often  a 
few  days,  the  other  upper  extremity  becomes  diseased.  There  may  be  no 
other  indications  of  syphilis,  but  usually  traces  of  past  syphilis  are  present 
in  the  parents.  Complete  recovery  ordinarily  ensues  in  from  two  to  three 
months  under  antisyphilitic  treatment  with  small  doses  of  mercury. 

Parasyphilitic  Affections.— Under  the  name  of  parasyphilitic  affections 
Fournier  in  particular  has  described  such  lesions  occurring  in  the  course  of 
syphilis  which  have  an  undoubted  etiological  connection  with  syphilis,  but 
are  not  really  of  syphilitic  nature,  and  do  not  react  to  a  specific  treatment. 
These  affections  include  leucoderma,  various  disturbances  of  the  central 
nervous  system  and  peripheral  nerves,  trophic  disturbances  of  the  muscles, 
bone,  etc. 

Syphilis  and  Carcinoma. — Occasionally  syphilis  is  observed  complicated 
by  carcinoma — i.  e.,  syphilitic  tissue  productions  become  the  seat  of  a  carci- 
noma, and  then  present  important  diflBculties  in  diagnosis  which  are  best 
solved  by  careful  microscopical  examination  and  antisyphilitic  treatment. 

The  combination  of  syphilis  with  tuberculosis  is  discussed  on  page  421, 

TTie  course  of  syphilis  is,  in  general,  very  chronic.  It  often  hap- 
pens that  the  syphilis  remains  latent  for  a  number  of  years  and  then 
breaks  out  afresh  with  severe  manifestations.  After  an  interval  of 
twenty  to  forty  years  local  tertiary  manifestations  sometimes  appear, 
particularly  in  the  skin,  the  central  nervous  system,  and  bones.  The 
syphilitic  poison  has  great  powers  of  resistance,  as  Fournier  in  par- 
ticular has  shown  by  numerous  observations.  Among  patients  with 
diseases  of  the  brain  and  spinal  cord,  we  find  a  great  number  who  have 
previously  had  syphilis  and  had  apparently  recovered,  Watraszewski 
has  stated  that  injuries  to  the  head  or  brain,  which  happen  before  or 
after  syphilis  is  acquired,  predispose  to  the  occurrence  of  syphilis  of 


44:4:  INFLAMMATION   AND   INJURIES. 

the  brain  early  in  the  disease.  What  appear  to  be  malignant  tumours 
not  infrequently  prove  to  be  gumniata,  which  appear  many  years  after 
an  attack  of  syphilis  that  has  apparently  been  cured. 

Immunity  from  Syphilis. — In  general  one  can  only  be  attacked  by 
syphilis  once ;  that  is,  a  j^atient  who  has  once  been  infected  becomes 
unsusceptible  to  the  poison — in  other  words,  immune.  The  immunity 
exists  from  the  time  the  syphilitic  enlai'gement  of  the  glands  takes 
place — indeed,  as  a  rule,  from  the  time  when  the  primary  initial  sclero- 
sis iirst  appears  (L.  Hudels),  and  generally  lasts  till  the  death  of  the 
individual  in  question.  Those  who  have  completely  recovered  suffer 
only  in  rare  instances  a  reinfection,  as  in  other  acute  infectious  diseases, 
and  these  reinfections  are  not  unjustly  doubted  by  various  authors. 

The  Soft  Chancre.— The  so-called  soft  chancre  {ulcus  molle,  see  Eegional 
Surgery),  unlike  the  primary  syphilitic  scleroma,  the  hard  chancre,  is  a  local 
ulcerative  process  which  usually  occurs  on  the  glans  penis,  the  foreskin,  vulva, 
or  labia,  and  may  lead  to  inflammation  and  suppuration  of  the  lymph  glands, 
but  never  produces  the  characteristic,  syphilitic,  constitutional  infection. 
There  has  been  much  discussion  between  two  parties — the  unitarians  and  the 
dualists — as  to  the  relationship  of  the  soft  chancre  to  syphilis.  At  present  the 
dualistic  view  is  the  most  generally  accepted — that  is,  that  the  soft  chancre 
is  an  ulcerative  process,  remaining  local,  and  has  nothing  to  do  with  syphilis. 
But  weighty  authorities  including  Hebra,  Auspitz,  Reder,  and  Kassowitz,  still 
insist  upon  the  unity  of  the  two  processes.  This  is  not  the  place  to  enter  more 
minutely  into  the  discussion,  and  we  shall  only  state  that  we  also  share  the 
dualistic  teachings  advanced  particularly  by  the  French  physicians,  and  we 
lay  particular  stress  upon  the  fact  that  the  chief  means  of  distinguishing  be- 
tween the  hard  and  soft  chancre  is  not  the  difference  in  hardness,  since,  as  a 
matter  of  fact,  the  so-called  soft  chancre  may  also  show  induration,  but  that 
the  difference  in  the  clinical  behaviour  is  the  single  and  only  means  of  irre- 
futably proving  that  the  primary  syphilitic  scleroma  and  the  ulcerated  chan- 
cre, which  remains  local,  have  nothing  to  do  with  one  anothei\  It  is  mainly 
the  long  period  of  incubation  of  the  hard  chancre,  and  the  impossibility  of 
auto-infection,  which  constitute  the  differences  between  it  and  the  localised 
soft  chancre.  The  latter  does  not  have  this  long  incubation,  and  is  capable 
of  being  inoculated  upon  other  portions  of  the  bearer's  body. 

Gonorrhoea. — Gonorrhoea  (see  Regional  Surgery)  also  has  nothing  to  do 
with  syphilis.  Gonorrhoea  is  either  a  simple  or  an  infectious  catarrh  of 
the  urethra  or  of  the  genital  tract,  and  is  produced  by  a  micrococcus,  the 
so-called  gonococcus,  first  discovered  by  Nei.sser.  Neisser  himself  states  that 
not  every  case  of  gonorrhoea  is  due  to  this  coccus,  but  that  there  is  also  a 
gonorrhoea  which  is  not  a  specific  infection.  Bockhardt  excited  gonorrhoea 
with  pure  cultures  of  the  gonococcus  in  a  paralytic  patient  during  the  termi- 
nal stage  of  his  cerebral  disease. 

Treatment  of  Syphilis — Treatment  of  the  Syphilitic  Primary  Infection. 
— If  syphilis  is  a  bacterial  disease,  as  it  undoubtedly  is,  it  would  seem 
a  necessary  part  of  the  treatment  to  extirpate  the  place  of  primary 


§84]  SYPHILIS.  445 

infection — that  is,  the  chancre — as  soon  as  possible ;  and  consequently 
Neisser,  Baumler,  and  others  have  recently  proposed  a  treatment  of 
this  sort  in  order  to  prevent,  or  at  least  to  modify,  the  constitutional 
manifestations  by  removal  of  the  primary  germ  focus.  On  the  other 
hand,  the  propriety  of  excising  the  primary  syphilitic  scleroma  has 
been  contested  on  the  ground  that  this  syphilitic  primary  infection  is, 
after  it  has  made  its  appearance,  the  expression  of  a  constitutional 
disease,  and  consequently  its  extirpation  is  of  no  avail.  I  consider  this 
view  incorrect ;  it  contradicts  our  present  knowledge  of  the  origin  of 
constitutional  disease  from  a  primary  focus  of  infection.  Like  Neisser, 
Baumler,  and  others,  I  also  try  to  destroy  the  primary  point  of  infec- 
tion in  syphilis  by  excision,  by  the  galvano-cautery,  etc.,  in  every  suit- 
able case  as  early  and  as  energetically  as  possible,  before  the  manifesta- 
tions of  the  constitutional  syphilitic  disease  make  their  appearance.  It 
is  only  by  very  early  excision  of  the  primary  lesion  that  it  is  possible 
to  prevent  the  outbreak  of  the  general  infection.  I  treat  every  sus- 
picious ulcer  in  the  same  way,  even  when  its  syphilitic  character  has 
not  been  rendered  certain.  Baumler  is  right  in  recommending  the  re- 
moval of  the  already  infected  glands  in  suitable  cases  in  addition  to  the 
excision  of  the  primary  lesion.  Syphilitic  ulcerations  which  appear 
later  are  best  treated  with  dusting  powders,  particularly  iodoform,  der- 
matol,  oxide  of  zinc,  bismuth,  or  boric  acid,  after  previously  cauterising 
them  with  solutions  of  carbolic  acid  (1  to  2  alcohol)  or  chloride  of  zinc 
(1  to  8),  caustic  potash,  formalin  10  to  40  per  cent.,  etc.  Washings  with 
bichloride  of  mercury  (0.1  to  100  water),  three-per-cent.  solutions  of 
carbolic  acid,  etc.,  are  also  to  be  recommended.  The  rest  of  the  treat- 
ment for  local  syphilitic  disease  is  conducted,  as  far  as  necessary,  ac- 
cording to  general  surgical  principles. 

Treatment  of  the  Syphilitic  Constitutional  Infection. — For  the  treat- 
ment of  the  syphilitic  constitutional  infection  we  have  two  remedies  at 
our  disposal  :  mercury  and  iodine.  Opinions  differ  as  to  the  value  of 
these  substances.  According  to  my  own  experience,  mercury  should 
be  used  in  the  early  period  of  constitutional  syphilis,  and  later  on  iodine 
and  mercury  in  alternation.  There  is  some  difference  of  opinion  as  to 
when  the  mercurial  treatment  should  begin.  Some  authorities  claim 
that  it  should  be  begun  as  soon  as  the  primary  lesion  appears,  while  others 
wait  for  the  constitutional  symptoms,  e.  g.,  the  glandular  enlargements. 
In  case  the  diagnosis  is  certain  the  treatment  may  begin  early — by  way 
of  prevention,  as  it  were,  and  in  this  case  the  disease  not  infrequently 
runs  a  very  mild  course.  The  methods  of  administering  mercury  are 
by  inunctions  of  ungt.  hydrara;.,  by  subcutaneous  injections  of  the  salts 
of  mercury,  and  by  the  internal  use  of  mercurials. 


4^6  INFLAMMATION  AND   INJURIES. 

Of  tlie  different  methods  of  treating  syi)liilis,  the  best  in  my  expe- 
rience is  the  inunction  of  ungt.  hjdrarg.  It  is  of  the  greatest  impor- 
tance that  the  inunction  treatment  should  be  carried  out  systematically, 
as  good  results  can  only  be  secured  in  this  way  and  a  cure  guaranteed. 
In  the  treatment  by  inunction,  three  to  live  grammes  (in  adults)  of  blue 
ointment  are  rubbed  daily  into  different  areas  of  skin  for  about  twenty 
minutes,  following  a  definite  order  (both  arms,  the  thigh,  the  forearms, 
the  legs,  chest,  abdomen,  and  back).  After  all  portions  of  the  body 
have  been  inuncted,  the  patient  then  takes  a  bath  and  begins  the  in- 
unctions anew,  following  the  same  order.  The  ointment  must  be 
rubbed  in  over  as  large  a  skin  surface  as  possible,  and  in  order  that  the 
patient  may  also  breathe  in  the  vapour  of  the  mercury,  he  should  re- 
main in  the  same  room  for  some  time,  wear  warm  clothing,  etc.  I 
usually  employ  three  grammes  for  each  of  the  first  ten  sittings,  four  for 
the  next  ten,  and  five  grammes  for  each  of  the  next  ten.  The  mouth 
must  be  kept  scrupulously  clean,  to  avoid  a  mercurial  stomatitis.  The 
teeth  must  be  cleaned  many  times  a  day  with  a  soft  toothbrush  wrapped 
in  mull,  using  tooth-powder  and  water.  Every  two  to  three  hours  the 
patient  should  gargle  his  throat  with  a  one-  to  two-per-cent.  solution  of 
chlorate  of  potash,  boric  acid,  etc.  Smoking  should  be  absolutely  for- 
bidden. If,  in  spite  of  all  this,  signs  of  stomatitis  appear,  greater  care 
must  be  bestowed  upon  the  mouth,  or  eventually  the  dosage  of  mercury 
diminished  or  the  mercury  stopped  entirely.  Unna  recommends  for 
inunctions  a  preparation  of  mercury,  lard,  and  green  soap,  which  after 
being  put  on  the  area  of  skin  in  question  is  rubbed  in  with  the  hand, 
which  is  dipped  in  hot  water  4  to  5  times.  He  claims  that  this  soap 
has  a  prompter  and  stronger  action  and  does  not  soil  the  underclothes. 

For  subcutaneous  injection  with  the  hypodermic  syringe  various 
double  salts  are  used,  such  as  mercuric  chloride,  sodium  chloride 
(hydrarg.  chlor.  corros.  0.1,  sodii  chlor.  1.0,  aq.  destil.  10.0,  one  half 
to  one  syringeful  a  day),  or  albuminate  compounds  of  mercuric  chlo- 
ride ;  0.1  gramme  of  the  selected  compound  is  injected  daily  into  dif- 
ferent portions  of  the  body,  particularly  the  breast  and  back,  or  intra- 
muscularly in  the  gluteal  region.  The  injections  which  used  to  be 
given  daily  were  very  inconvenient,  and  they  are  at  present  made  less 
often — every  five  to  eight  days,  for  example — and  preference  is  given 
to  the  use  of  insoluble  salts  of  mercury,  particularly  calomel,  hydrarg. 
oxidum  flavum,  etc.,  which  are  best  injected  intramuscularly  in  the 
gluteal  region.  Injections  of  calomel  (0.05  to  0.2  gramme)  in  glycer- 
ine, oil,  or  salt  water,  at  intervals  of  four  to  eight  days,  are  used  very 
frequently.  Kopp,  Striimpell,  and  others  recommend  injections  of  an 
emulsion  of  calomel  in  water  with  sodium  chloride  (calomel  vap.  parat. 


§84]  SYPHILIS.  447 

5.0,  sod.  ehlor.  1.25,  aq.  destil.  50.0,  one  gramme  to  be  injected  once  a 
week,  altogether  four  to  six  times).  Calomel  oil  (1  to  10)  is  exceedingly 
good,  two  syringefuls  on  the  first  day,  and  two  more  fourteen  days  after- 
wards, or  every  eight  days  one  syringeful  (0.1  gramme  calomel ;  Neis- 
ser,  Doutrelepont,  Bergmann).  Prochorow  recommends  one  to  two  per 
cent,  cyanide  of  mercury  (one  hypodermic  syringeful — altogether  about 
twenty  to  twenty-live  injections).  Mention  should  be  made  of  the 
following  methods  of  injection  :  Hydrarg.  oxid.  nigr.  or  hydrarg.  oxid. 
rubr.  laevig.  1.0,  gummi  arab.  0.50,  aq.  destil.  10.0,  or  1  to  10  ol.  oliv. ; 
a  syringeful  of  this  to  be  injected  altogether  three  to  five  to  seven 
times  at  intervals  of  a  week.  In  a  similar  manner  use  is  made  of  the 
very  excellent  hydrarg.  oxid.  flav.  1.0,  gummi  arab.  0.25,  aq.  destil.  30, 
or  1  to  30  ol.  amygdal.  or  olivse  (Striimpell),  every  week  a  syringeful 
in  the  gluteal  region,  four  to  six  to  eight  times.  These  injections  are 
not  so  painful  as  calomel  injections,  and  the  formation  of  abscesses  is 
more  easily  avoided.  E.  Lang  has  practised  injections  for  many  years, 
with  the  best  results,  with  oleum  cinereum — i.  e.,  a  fifty -per-cent.  mix- 
ture of  blue  ointment  with  lanolin  and  olive  oil.  Every  five  to  eight 
days,  0.1  to  0.15  of  a  cubic  centimetre  of  the  ointment  is  injected  in 
the  back  or  rump.  The  thymolate  and  the  salicylate  of  mercury  have 
been  used  a  good  deal  for  injections — e.  g.,  hydrargyri  salicyli  0.20, 
mucil.  gummi  arab.  0.30,  aq.  destillat.  60.0,  six  to  twelve  injections  at  in- 
tervals of  two  to  three  days.  Injections  of  the  salicylate  are  sometimes 
followed  by  a  rise  of  temperature,  night-sweats,  polyuria,  and  other 
sequelae.  Leichtenstern  and  Eich  observed  recurrences  in  more  than 
thirty  per  cent,  of  the  cases  treated  by  the  salicylate  of  mercury,  and 
in  some  of  these  cases  the  recurrence  took  place  soon  after  the  comple- 
tion of  the  cure.  Lassar  recommends  for  severe  forms  of  syphilis  in- 
jections of  five  per  cent,  bichloride.  The  mercurial  injections  are 
somewhat  painful,  and  must  be  made  by  the  physician  himself  and 
under  antiseptic  precautions,  in  order  to  prevent  the  formation  of 
abscesses.  The  injection  method  is  a  very  convenient  one  for  dis- 
pensary and  private  practice,  but  I  doubt  whether  it  is  as  efiicacious  as 
the  inunction  treatment.  In  my  experience,  recurrences  are  more  com- 
mon after  the  injection  treatment  than  after  the  inunction  method. 
The  action  of  the  insoluble  salts  in  particular  is  weaker  and  not  so  last- 
ing, and  yet,  in  spite  of  this,  poisoning  is  not  infrequently  observed. 
In  a  few  cases  injections  of  insoluble  salts  of  mercury  have  been  fol- 
lowed by  pulmonary  embolism,  with  paroxysms  of  coughing,  cardiac 
weakness,  bloody  expectoration,  and  circumscribed  infiltration  of  the 
lungs  (Harttung).  Tomraasoli  praises  the  curative  action  of  injections 
of  the  blood  serum  of  lambs  (2  to  8  cubic  centimetres  daily).     This 


448  INFLAMMATION   AND   INJURIES. 

blood-serum  therapy  of  syphilis  is  analogous  to  the  treatment  of  other 
infectious  diseases  with  the  blood  serum  of  animals  which  have  been  made 
immune  from  the  infectious  disease  in  question.  These  injections  of 
the  blood  serum  of  innnune  animals  (sheep,  dog,  rabbit)  are,  according 
to  the  view  of  most  authorities,  without  therapeutic  value.  The  serum 
of  individuals  with  tertiary  syphilis  has  also  been  injected  into  those 
recently  infected,  in  order  to  furnish  the  latter  with  the  anticoxine  of 
syphilis,  and  thus  make  them  immune  to  the  secondary  manifestations 
(Bock).  These  experiments  will  also  requi]-e  further  trial  before  we 
can  give  a  correct  judgment  in  the  matter. 

Internally  the  following  preparations  are  especially  used  :  Bichlo- 
ride of  mercury  (0.05  to  0.1  gr&mme  pro  die)  and  calomel  (0.05  to  0.1 
gramme,  three  times  a  day  in  pill  or  powder).  Calomel  is  also  given 
in  large  doses  (e.  g.,  0.1  to  0.5  gramme  mornmg  and  evening),  when  it 
is  desired  to  obtain  the  effects  of  mercury  quickly.  Lustgarten  and 
others  have  recommended  hydrarg.  tannicum  oxydulatum  in  powder  or 
pill  form,  according  to  the  following  formula  :  Hydrai-g.  tannici  oxyd- 
ulat.  4.0  grammes,  extr.  et  pulv.  liquirit.  q.  s.  ad.  pilul.  no.  60  ;  three 
to  five  pills  a  day  for  adults,  for  children  smaller  doses  of  0.02  to  0.03 
gramme.  Gamberini,  Schadeck,  and  others  recommend  hydrarg.  car- 
bol.  oxydat.  (hydrarg.  carbol.  oxyd.  1.2  gramme,  extr.  et  pulv.  liquirit. 
q.  s.  ut  f .  m.  pilul.  no.  60,  two  to  four  pills  daily).  Schadeck  has  also 
recommended  this  remedy  for  subcutaneous  injections  (hydrarg.  car- 
bol. oxyd.  2.0,  mucil.  gummi  4.0,  aq.  destil.  100.0,  one  syringeful  [0.02 
of  the  hg.  salt]  every  two  to  three  days).  Recently  the  salicylate  of 
mercury  has  been  much  used  internally  (1.0  gramme  in  60  pills,  three 
to  four  pills  daily). 

Excretion  of  Mercury— Mercurial  Cachexia. — According  to  recent  inves- 
tigations, mei'cury  is  excreted  mainly  in  the  faeces  and  in  the  urine,  but  in 
the  latter  not  constantly.  The  excretion  of  mercury  in  the  fseces  continues 
for  weeks  or  months  after  the  treatment  has  ceased.  Schuster  found  the 
faeces  free  from  mercury  one  year  after  the  cure.  Vajda,  Paschkis,  and  Ober- 
lander  came  to  the  conclusion  that  mercury  is  sometimes  retained  within 
the  body  for  years.  In  former  times,  especially,  the  use  of  mercury  was 
dreaded  because  there  would  occasionally  arise  an  incurable  mercurial  poi- 
soning (mercurial  cachexia).  It  is  a  generally  accepted  fact  at  the  present 
time  that  this  trouble  can  be  avoided  with  certainty  by  careful  use  of  the 
remedy. 

Iodine  is  suited,  particularly  for  the  late  period,  for  the  gummatous 
inflammations,  though  it  is  also  given  by  many — Zeissel,  for  instance — 
in  the  early  stages.  He  only  employs  mercury  late  in  the  disease 
and  in  necessary  cases.  Iodide  of  potassium  or  iodide  of  sodium  is 
given  in  a  dose  of  about   one   to  two  grammes,  seldom  more  (8  to 


§  84.]  SYPHILIS.  449 

10  grammes),  daily,  best  in  aqueous  solution.  In  suitable  cases  very 
large  doses  of  iodide  of  potassium  (20  to  30  grammes  and  more  ])ro 
die)  have  been  administered,  accompanied  by  a  milk  and  meat  diet, 
with  bromide  of  potassium  and  antipyrine  to  prevent  the  iodism  and 
headache.  Many  recommend  the  simultaneous  use  of  the  iodine  and 
mercurial  treatment.  Giintz  praises  bichromate  of  potassium,  particu- 
larly for  syphilis  maligna  (one  bottle  of  chromium  water  every  day 
with  0.03  gramme  of  bichromate  of  potassium).  In  syphilis  maligna 
mercury  should  be  used  with  the  greatest  caution.  Iron  and  the  qui- 
nine preparations  are  to  be  recommended,  as  well  as  a  strengthening 
diet,  proper  hygienic  measures,  and  iodide  of  potassium,  together  with 
a  suitable  local  treatment. 

The  proper  nutrition  of  the  patient  should  be  carefully  attended  to  ; 
a  moderate  amount  of  alcohol  should  be  permitted,  and  exercise  in  the 
fresh  air  is  desirable,  etc.  In  the  inunction  treatment,  particularly, 
attention  should  be  paid  to  keeping  the  bowels  regular. 

For  recurrences,  constitutional  treatment,  best  by  inunctions,  should 
always  be  undertaken  again  for  a  time. 

It  is  well  known  that  occasionally,  after  an  apparent  cure  which  may 
have  lasted  years,  severe  local  and  constitutional  manifestations  make 
their  appearance.  For  preventing  this,  Fournier  and  Neisser  have 
urgently  recommended  the  use  of  mercury  or  iodine  for  one  and  a 
half  to  two  years  at  proper  intervals  after  the  syphilis  has  been 
apparently  cured.  When  possible,  I  usually  give  a  course  of  inunctions 
every  half  year  for  four  years  after  infection,  even  in  the  cases  that 
are  cured.     I  alternate  a  mild  course  with  a  more  severe  one. 

In  children  with  hereditary  syphilis,  for  example,  it  is  an  excellent 
plan  to  use  mercurial  baths  (2  to  5  grammes  in  a  bath  lasting  half  an 
hour).  The  internal  administration  of  calomel  (0.005  to  0.01  gramme 
twice  daily)  or  of  bichloride  of  mercury  (0.005  gramme  jp7'o  die)  easily 
produces  disturbances  of  digestion. 

It  is  a  very  good  plan  to  carry  out  the  inunction  treatment  in  some 
resort  where  baths  or  mineral  waters  can  be  employed.  In  this  way 
the  metabolism  is  stimulated — i.  e.,  both  the  syphilitic  poison  and  the 
mercury  are  eliminated  in  greater  amounts,  so  that  the  latter  can  be 
employed  in  larger  doses  even  in  weak  patients.  I  can  recommend 
Tolz,  Wiesbaden,  and  particularly  in  old  cases  the  sulphur  springs  in 
Aix,  l^euendorf,  etc.  In  a  resort  of  this  sort  the  patient  devotes  him- 
self entirely  to  his  treatment,  which  he  can  often  not  carry  out  at  home. 

In  the  treatment  of  syphilis,  the  healthy  individuals  with  whom  the 
patient  constantly  comes  in  contact  should  always  be  protected  from 
infection  by  proper  precautions. 


450  INFLAMMATION   AND   INJURIES. 

It  is  probable  that  the  mercurial  treatment  of  pregnant  women  can 
also  exert  a  direct  influence  upon  the  syphilis  of  the  foetus  infected  at 
the  time  of  conception,  as  Zweifel,  Gusserow,  and  others  have  proved 
that  various  drugs,  like  chloroform,  salicylic  acid  or  iodine  may  pass 
from  the  maternal  into  the  foetal  circulation.  Syphilis  and  tuberculosis 
are  the  two  greatest  scourges  of  the  human  race,  and  thev  will  neces- 
sarily prove  very  disastrous  to  future  generations  as  well.  It  is  of  the 
greatest  importance  that  syphilis  should  be  combated  with  the  great- 
est energy  by  governmental  regulations,  and  particularly  by  legal  and 
medical  supervision  of  prostitution. 

§  85.  Leprosy  {Leprci). — By  lepra  {elephantiasis  Grmcorum)  or  lep- 
rosy is  understood  a  chronic  infectious  disease  which  is  caused  by  the 
Bacillus  leprce^  first  discovered  by  Hansen  and  Neisser,  and  is  character- 
ised anatomically  by  more  or  less  circumscribed  inflammatory  growths, 
particularly  in  the  skin  and  nerves.  According  to  A,  Hansen  and 
Bergmann,  lepra  is  contagious,  but  not  in  the  ordinary  sense  of  the 
word,  as  the  attendants  upon  such  patients  are  only  very  rarely  affected 
by  the  disease  (Beaven).  Bergmann  found  contagion  to  be  the  excit- 
ing cause  in  sixty  per  cent,  of  the  cases  (one  hundred  and  eight).  The 
contagiousness  of  leprosy  cannot  be  proved  by  the  inoculation  of  ani- 
mals, as  the  bacilli  of  leprosy  can  apparently  live  only  in  human  sub- 
jects. In  some  places,  such  as  the  coast  of  the  Baltic  Sea,  leprosy  is 
chiefly  a  disease  of  the  poor,  who  live  in  the  most  wretched  and  filthy 
surroundings.  In  the  tropics — e.  g.,  in  India — Europeans  of  the 
better  class  may  acquire  the  disease  from  association  with  the  diseased 
natives,  and  this  is  particularly  likely  to  occur  if  their  power  of  resist- 
ance has  been  diminished  by  the  tropical  climate.  In  my  opinion,  the 
endemic  extension  of  the  disease  can  only  be  explained  by  the  assump- 
tion that  it  is  contagious,  and  it  can  only  be  successfully  combated  by 
regulations  aimed  at  protection  and  isolation.  Transmission  by  inherit- 
ance can  only  rarely  be  proved,  the  disease  in  these  cases  originat- 
ing for  the  most  part  in  the  family  by  contact  from  person  to  person. 

The  Lepra  Bacilli  (Fig.  343),  first  demonstrated  by  Armauer  Hansen 
and  then  by  Neisser,  are  small  rods  about  four  to  six  ja  long  and  almost  one 
|i  broad,  and  are  exactly  similar  to  the  tubercle  bacilli,  except  that  they  ai^e 
somewhat  shorter.  The  lepra  bacilli  are  incapable  of  spontaneous  movement. 
It  is  impossible  as  yet  to  say  whether  the  bright  egg-shaped  or  round  uncol- 
oured  spots,  which  come  out  when  the  bacilli  are  stained,  are  to  be  regarded 
as  spores  or  not.  The  bacilli  are  found  in  the  leprous  new  growths  in  the 
skin,  nerves,  lymph  glands,  spleen,  liver,  and  testicle,  usually  in  great  num- 
bers, partly  free  in  the  tissues  and  partly  within  the  cells  in  the  so-called 
*' lepra  cells"  (Fig.  343,  Neisser,  Leloir,  etc.).  These  cells  are,  some  of  them, 
large  mononuclear  cells,  while  others  are  like  leucocytes.    Wynne  found  the 


§  85.]  LEPROSY.  451^ 

bacilli  also  in  spindle-shaped  granulation  cells,  and  in  rare  cases  in  giant  cells, 
sometimes  in  great  numbers  (Boinet,  Borrel).  According  to  Unua,  the  ba- 
cilli lie  preferably  in  the  lymph  spaces  of  the  tissues,  and  the  collections  of 
the  bacilli  designated  as  "  lepra  cells  "  are  artificial  products,  as  he  thinks 
has  been  proved  by  his  drying  method.  After  decolorising  the  preparation 
in  nitric  acid  and  distilled  water,  he  dehydrated  it,  not  by  alcohol  but  by 
heating  it  over  a  flame,  and  then  clarified  it  with  xylol.  Neisser  and 
Wynne,  in  particular,  have  contested  this  view  of  Unna's. 

The  lepra  bacilli  can  be  stained  in  the  same  manner  as  the  tubercle  ba- 
cilli, but  more  easily  and  rapidly,  by  using,  for  instance,  solutions  like  those 
of  Ziehl  and  Ehrlich.  Gram's  method  is  also  very  useful.  Baumgarten's 
method  of  staining  is  as  follows  :  6  to  7  minutes  in  a  diluted  alcoholic  solution 
of  fuchsin,  then  decolourise  for  one-fourth  of  a  minute  in  acidified  alcohol 
(nitric  acid  and  alcohol  1 :  10),  wash  off  in  water  and  stain  in  aqueous  solu- 
tion of  methylene  blue.  Lustgarten  uses  the  following  stain  :  Stain  with 
aniline  water,  fuchsin,  or  gentian  violet,  and  decol- 
ourise for  a  considerable  time  in  one  per  cent,  sub- 
chloracetate  of  sodium  and  wash  oflF  thoroughly  in 
water.  The  artificial  cultivation  of  the  bacilli  and 
their  successful  inoculation  upon  animals  has  hith- 
erto been  accompanied  with  difficulties,  and  though 
,,  ■■  J      n  i.     J.     n         J.     ii  -e  it.  Fig.  343. — Lepra  cells  with 

there  can  be  no  doubt  at  all  as  to  the  specihc  patno-        bacilli,    x  700  (Flugwe). 

genie  significance  of  the  bacilli,  still  a  perfectly  satis- 
factory proof  of  their  specific  action  has  not  as  yet  been  obtained.  Bordoui- 
TJffreduzzi  was  the  first  to  cultivate  the  bacilli  obtained  from  the  bone  marrow 
of  a  man  dying  of  leprosy ;  he  cultivated  them  at  the  incubator  temperature 
upon  hardened  blood  serum  to  which  had  been  added  peptone  and  glycerine, 
and  after  several  days  obtained  band-like,  whitish-grey  colonies  with  in- 
dented borders  made  up  of  bacilli  of  different  lengths,  generally  with  a  club- 
shaped  enlargement  at  the  ends.  Inoculations  upon  animals  were  unsuccess- 
ful, because  the  strictly  parasitic  bacteria  rapidly  lose  their  virulence  when 
cultivated  outside  the  body  (Bordoni-Uffreduzzi,  Baumgarten).  Melcher  and 
Ortmann  claim  to  have  made  successful  inoculations  upon  rabbits.  In  the 
human  subject  also  inoculation  with  the  bacilli  appears  to  be  very  difficult 
or  almost  impossible  ;  Arning  alone  was  able  to  inoculate  successfully  a  con- 
demned criminal  by  means  of  particles  of  tissue  from  leprous  nodes.  It  is 
certain  that  man  is  the  chief  sufferer  from  the  leprous  poison  :  but  how  the 
disease  originates  in  man  and  spreads  is  still  uncertain.  In  the  majority  of 
cases  the  disease  appears  to  spread  from  person  to  person  by  contact — that  is, 
by  direct  contagion  ;  inheritance  plays  a  small  part.  Hutchinson's  idea  that 
leprosy  is  spread  by  eating  fish  is  contested  by  a  great  many.  According  to 
Hansen,  leprosy  is  not  inheritable.  In  some  leprous  districts  the  disease  is 
transmitted  by  vaccination,  and  is  said  to  have  originated  and  spread  in  this 
way  on  the  Hawaiian  Islands  (Arning,  Tebb).  A-^accination  should  accord- 
ingly be  performed  with  great  care  in  leprous  districts  in  order  that  the 
leprosy  bacilli  may  not  be  inoculated  with  the  vaccine  lymph.  Wahl  main- 
tains that  leprosy  originates  preferably  in  the  periphery  of  the  body — that  is, 
in  the  exposed  skin  and  mucous  membrane  of  the  pharynx  and  larynx,  and 
then  very  gradually  extends  to  the  internal  organs  by  means  of  the  lymph 


452  INFLAMMATION  AND  INJURIES. 

channels.  According  to  Thoma,  the  leprous  new  formation  begins  in  the 
inner  layers  of  the  skin,  in  the  perivascular  spaces,  and  in  the  immediate 
neighbourhood  of  the  smaller  blood-vessels,  and  then  penetrates  into  the  sub- 
cutaneous fatty  tissue,  the  lymph  vessels,  and  lynipli  glands.  Leprosy  attacks 
almost  all  the  organs  of  the  body,  but  is  localised  particularly  in  the  skin 
and  peripheral  nerves.  Nodules  are  gradually  formed  like  those  in  tuber- 
culosis. Large  nerves,  like  the  median  and  ulnar,  may  swell  into  strands 
the  size  of  a  finger.  In  the  nerves  of  a  patient  with  lepra  ana^sthetica  the 
bacilli  are  found  in  the  nerve  fasciculi,  and,  besides  atrophy  and  disappear- 
ance of  the  nerve  fibres,  there  is  an  interstitial  sclerosis  with  sometimes  cal- 
careous infiltrations.  In  the  nerve  sheaths  the  leprous  disease  extends  chiefly 
towards  the  central  nervous  system,  and  in  the  diseased  area,  there  may  be 
a  complete  destruction  of  the  nerves,  in  consequence  of  which  a  descending 
(not  leprous)  degeneration  takes  place  in  the  separated  portion  of  the  peri}ih- 
eral  nerves,  involving  both  the  motor  and  sensory  fibres.  This  explains  why 
every  sign  of  leprous  disease  is,  in  certain  cases,  absent  in  the  peripheral 
nerves  of  the  area  of  skin  rendered  anaesthetic ;  in  such  cases  the  disease 
is  located  in  parts  of  the  nerves  more  centrally  situated  (Dehio,  Gerlach). 
Of  the  internal  organs,  the  lymph  glands,  spleen,  and  liver  are  most  frequently 
diseased.  In  the  blood  usually  no  bacilli  can  be  demonstrated :  but  Kobner, 
Thoma,  and  Doutrelepont  have  seen  them  in  the  blood  and  the  capillaries  of 
the  liver.  According  to  Winiarski,  the  number  of  red  corpuscles  is  reduced 
in  the  most  severe  cases  to  one  third,  and  the  percentage  of  haemoglobin  to 
three  fifths  of  the  normal.  The  number  of  leucocytes  is  in  general  normal, 
and  the  poly  nuclear  leucocytes  are  much  the  most  numerous.  The  blood 
coagulates  very  quickly  (Bake). 

Occurrence  of  Leprosy. — Leprosy  has  been  known  since  the  earliest  times, 
and  during  the  middle  ages  was  distributed  through  almost  all  the  countries 
of  Europe.  At  present,  in  Europe,  the  disease  is  found  only  in  Sweden,  Nor- 
way, Finland,  in  the  Russian  Baltic  provinces  and  on  the  coasts  of  the  Medi- 
terranean and  Black  Seas,  and  most  frequently  on  the  coasts  of  Norway  and 
in  the  south  of  Spain.  Leprosy  is  widely  distributed  in  different  parts  of 
Asia  (Asia  Minor,  Persia,  China,  India),  in  America  (Central  America,  north 
and  east  coasts),  in  Africa  (Cape  Colony),  and  in  Australia. 

Symptomatology  of  Leprosy. — Leprosy  usually  begins  very  insidi- 
ously, the  duration  of  the  incubation,  according  to  Bergmann  and 
others,  generally  being  three  to  four  to  five  years.  This  explains  the 
apparent  immunity  of  children  to  leprosy.  A  general  distinction  is 
made  between  leprosy  of  the  skin  and  of  the  nerves,  though,  for  the 
most  part,  they  occur  in  coml^ination.  Leprosy  of  the  skin  is  observed 
particularly  on  the  face  and  on  the  hands  and  feet,  and  especially  on 
the  extensor  aspect  of  the  knee  and  elbow  region.  The  face  shows  early 
a  characteristic  expression  (flattening  of  the  eyebrows,  facial  paralysis 
with  oblique  position  of  the  mouth,  inability  to  close  the  eyes,  etc.). 
Ulcerative  processes  soon  occur  on  the  fingers.  The  skin  has  a  charac- 
teristic pale,  waxy  appearance.  Hypereemic  spots  (lepra  rubra)  are 
seen  in  the  skin  of  different  parts  of  the  body,  which  either  disappear, 


§85.] 


LEPROSY. 


453 


leaving  behind  a  pigmentation,  or  gradually  grow,  forming  brownish- 
red  nodes  the  si^ie  of  a  walnut  (lepra  tuberosa).  The  nodes,  consisting 
essentially  of  granulation  tissue,  may  remain  stationary  for  a  long  time, 
or  they  may  break  down  and  form  ulcers,  particularly  when  subjected 
to  external  injurious  influences.  The  leprous  nodes  develop  the  most 
vigorously  upon  the  face,  sometimes  singly,  but  generally  in  groups, 
forming  whole  clusters.     In    consequence  of  the   coalescence  of  the 

nodes  thick  masses  result  on  the 
eyebrows,  the  alse  of  the  nose,  the 


^^-i^^  i^M^' 


Fig.  344. — Leprosy  of  the  face  (leontiasis  lepra 
s.  lepra  leoninaj,  after  Munch. 


Fig.  345. — Lepra  leonina ;  forty-year-old  leper 
from  Cape  Colony  (Fritsch  anJi  Virchow). 


lips  and  chin,  so  that  the  physiognomy  of  such  a  patient  assumes  an 
expression  more  or  less  like  that  of  an  animal,  and  hence  the  designa- 
tion lepra  s.  facies  leonina,  or  leontiasis  (Figs.  344  and  345). 

The  leprosy  of  the  nerves  (lepra  nervorum  ansesthetica,  lepra  mu- 
tilans) begins  with  hypersesthesia  and  pain ;  then  aneesthesia  usually 
follows,  with  trophic  disturbances  consisting  in  the  formation  of  white 
and  brown  spots  and  in  atrophy  of  the  muscles  and  bones.  Motor 
paralyses  are  less  common.  As  a  result  of  the  anaesthesia,  injuries  are 
not  noticed  and  lead  to  ulcerative  processes,  in  consequence  of  which 
parts  of  the  fingers  and  toes  may  be  lost  (lepra  mutilans).  The  nerves 
affected  by  leprous  disease  become  thickened,  particularly  between  the 
nerve  fibres  and  in  the  neurilemma,  as  the  result  of  an  interstitial 
sclerosis,  sometimes  combined  with  deposits  of  lime,  etc.  Lepra  nervo- 
rum is  essentially  a  degenerative  neuritis  ascending  from  the  periph- 
ery to  the  centre.  This  has  been  briefly  described  on  page  452.  In 
some  cases  a  complex  of  trophic  and  sensory  disturbances  is  observed 


454 


INPLAMMATIOX  AND   INJURIES. 


wliicli  resembles  syringomyelia.  There  is  no  fundamental  difference 
between  the  two  main  forms  of  leprosy,  the  anaisthetic  and  the  nodular. 
Besides  the  skin  and  nerves,  the  disease  affects  particularly  the 
lymph  glands,  then  the  mucous  membranes,  the  eyes,  nose,  mouth, 
larynx,  and  also  the  liver,  spleen,  and  testicles.  Arning  has  described 
a  mihary  leprosy,  particularly  of  the  serous  membranes,  which  is  simi- 
lar to  miliary  tuberculosis.  In  some  of  the  cases  there  is  probably  a 
mixed  infection  with  tuberculosis.  Hansen  and 
Looft  are  of  the  opinion  that  Arning's  cases  should 
be  regarded  as  pure  tuberculosis,  and  not  as 
leprosy. 

Prognosis. — The  disease  generally  terminates 
after  a  varying  length  of  time — one  to  two  to  five 
to  twenty  years — with  death  either  from  exhaus- 
tion or  some  intercurrent  affection,  not  infre- 
quently from  tetanus.  Lepers  not  uncommonly 
suffer  from  tuberculosis  at  the  same  time,  and  die 
of  this  (Phillipson). 

Diagnosis. — At  the  beginning  of  the  disease  the 
diagnosis  of  lepra  can  present  manifold  difficul- 
ties. For  its  diagnosis  in  the  early  stage  the  char- 
actei'istic  changes  in  the  face  are  important.  The 
nodular  form  may  be  confused  with  syphilis,  the 
anaesthetic  with  syringomyelia.  Close  questioning 
of  the  patient,  the  histological  demonstration  of 
the  lepra  bacilli,  and  finally  an  antisyphilitic  coarse  of  treatment, 
may  establish  the  diagnosis  in  doubtful  cases.  In  syringomyelia,  as 
opposed  to  lepra  ansesthetica,  there  is  usually  only  a  partial  disturbance 
of  the  sensory  sphere — for  instance,  analgesia  and  thermo-ansesthesia, 
with  persistence  of  the  tactile  and  muscular  sense  (P.  A.  Morrow).  It 
can  be  differentiated,  furthermore,  from  syringomyelia  and  Morvan's 
disease  by  the  thickenings  of  the  nerves,  the  pigmentation  of  the  spots, 
the  nodules,  and  by  the  presence  of  the  leprosy  bacilli. 

Treatment  of  Leprosy. — Though  opinions  differ  as  to  the  conta- 
giousness of  lepra,  still  all  authorities  are  agreed  that  it  is  very  neces- 
sary for  general  hygienic  reasons  to  isolate  and  confine  the  patients  in 
institutions  for  the  purpose.  The  isolation  of  lepers  should  be  regu- 
lated by  international  laws.  It  is  particularly  important  to  prevent  a 
spread  of  the  disease  from  one  country  to  another,  which  can  take 
place  so  easily  owing  to  the  extensive  communication  by  water  that 
now  exists.  In  localities  where  leprosy  exists  the  disease  is  combated 
best  by  isolation  of  the  patients  and  improvement  of  the  social  and 


Fig.  346.  —  Lepra  anse.?- 
thetica  mutilans  with 
loss  of  the  tincrer-tips ; 
four  ulcers  of  tlie  palm 
in  a  man  thirty  -  six 
years  of  age,  who  had 
lived  in  the  tropics. 


§86.]  ACTINOMYCOSIS.  455 

hygienic  conditions.  Energetic  measures  of  protection  and  isolation 
have  caused  a  diminution  of  fifty  per  cent,  in  the  amount  of  leprosy 
in  Sweden  within  twenty  years.  As  yet  we  do  not  know  any  specific 
remedy  for  the  disease,  and  consequently  the  treatment  is  essentially  a 
symptomatic  one,  consisting  mainly  in  proper  hygiene,  warm  baths,  and 
the  administration  of  tonics.  In  febrile  attacks  antipyretics  are  given. 
For  the  local  treatment,  Bidenkap,  an  excellent  authority  on  leprosy, 
recommends  goa  powder  or  chrysarobin,  which  he  applies  to  the  node& 
and  spots  on  adhesive  plaster.  Unna  also  recommends  chrysarobin, 
and  others  aristol,  salol,  creosol,  hydroxylamin,  europhen,  etc,  Eibb 
speaks  favourably  of  chaulmoogra  oil,  Keissner  of  gurjun  balsam  (five 
drops  a  day  internally,  gradually  increased  to  seventy  and  more ;  in 
case  of  irritation  of  the  stomach  or  kidneys  it  should  be  stopped). 
The  latter  is  also  given  in  the  form  of  inunctions  (three  parts  gur- 
jun and  one  part  lanolin).  Balz  recommends  the  daily  application  to 
the  skin  of  a.  thick  layer  of  a  twenty  per  cent,  salicylic  ointment  con- 
sisting of  salicylic  acid,  lanolin,  and  vaseline  combined  with  the  internal 
use  of  gynakadia  oil  in  large  doses  (fifteen  grammes  and  more  a  day) 
and  warm  baths.  In  suitable  cases  surgical  treatment  has  to  be  adopted. 
Mitra  and  others  have  employed  nerve-stretching  to  advantage  in 
the  early  stages  of  ansesthetic  leprosy.  Creamer  scrapes  the  diseased 
areas  with  the  sharp  spoon.  In  general,  wounds  in  leprous  subjects 
heal  quickly  and  well ;  the  rapid  coagulation  of  the  blood  is  very  strik- 
ing. Massage  of  the  nodules  and  thickened  nerves  is  useful  in  many 
instances.  It  is  possible  to  make  the  nodules  and  spots  disappear  in 
a  variety  of  ways,  but  we  cannot  cure  the  disease.  "Whether  we  shall 
sometime  procure  a  curative  serum  for  leprosy  similar  to  the  anti- 
diphtheritic  serum  the  future  alone  will  show. 

§  86.  Actinomycosis. — By  actinomycosis  is  understood  a  progressive 
inflammation  and  suppuration  excited  by  the  ray  fungus  or  actino- 
myces  (Fig.  347),  which  is  observed  particularly  in  cattle,  swine,  and 
man,  and  is  transferable  by  inoculation  (Bollinger,  Israel,  Ponfick, 
Wolff).  Though  the  actinomyces  used  to  be  ranked  among  the  mould 
fungi  (hyphomycetes),  Bostroem,  in  1885,  showed  by  a  special  method 
of  cultivation  that  it  belonged  to  the  fission  fungi  (schizomycetes),  and 
was  to  be  regarded  as  a  variety  of  cladothrix  with  branches.  Bollinger 
discovered  the  actinomyces  in  cattle,  Israel  in  man,  while  Ponfick  was 
the  first  to  prove  the  identity  of  the  actinomycosis  of  cattle  with  that 
of  man. 

Actinomyces. — In  the  actinomycotic  tumours  or  abscess-like  foci  there 
are  found  characteristic,  yellow,  solid  granules  the  size  of  a  grain  of  hemp. 
If  these  granules  are  crushed  and  the  preparation  stained  for  half  an  hour  in 


456 


INFLAMMATION  AND   INJURIES. 


hot,  carbolised  fuchsin,  or  for  twenty-four  liours  in  an  aqueous  solution  of 
gentian  violet,  and  tlien  placed  for  ten  to  fifteen  minutes  in  a  solution  of 
iodine  in  iodide  of  potassium,  then  in  alcohol,  etc.,  aiid  examined  under  the 

microscope,  these  granules  will  be  seen 
to  consist  of  a  characteristic  stellate 
arrangement  of  branching  filaments 
which  radiate  from  a  common  centre 
and  possess  peculiar  club-shaped  en- 
largements (Fig.  M7).  Similar  yellow 
granules  sometimes  occur  in  suppura- 
tive processes  that  are  not  actinomy- 
cotic in  nature,  and  consist  of  different 
varieties  of  fungi  (pseudo-actinomy- 
cosis,  Paltautf,  Illich).  The  micro- 
scopic examination  of  the  granules  will 
alone  show  whether  the  case  is  one  of 
real  actinomycosis.  In  every  colony 
of  actinomycetes  it  is  possible  at  a 
certain  stage,  according  to  Bostroem, 
to  distinguish  thi-ee  elements  :  1,  Club- 
shaped  formations  ;  2,  a  centrally 
placed  network  of  fungous  filaments 
of  varying  shape  and  size ;  3.  fine, 
coccus-like, bodies  (spores),  which  oi-ig- 
inate  from  the  fungous  filaments  and 
grow  into  long  rods  and  branching 
twigs.  According  to  Wolff  and  Israel, 
the  significance  of  the  coccus -like 
bodies  is  still  obscure.  Domee  states  that  the  spores,  which  can  be  best 
examined  in  potato  cultures  made  at  a  temperature  of  22°  to  24°  C,  originate 
by  transverse  segmentation  of  the  peripheral  filaments,  like  the  arthrospores 
in  the  aspergillus,  for  example.  Accoi'ding  to  Bostroem,  who  was  the  first  to 
make  pure  cultures  of  the  actinomyces,  and  according  to  Moosbrugger,  the 
•central  network  of  filaments  grows  rapidly  and  luxuriantly,  while  the  nodes 
of  the  glands  are  to  be  looked  upon  as  products  of  degeneration  incapable  of 
further  development.  This  is  contested  by  Partsch.  M.  Wolff  and  J.  Israel 
have  cultivated  the  actinomyces,  in  the  absence  of  oxygen,  upon  agar  and  in 
the  interior  of  raw  hens'  eggs,  and  have  successfully  inoculated  these  pure 
cultures  upon  rabbits  by  injection  into  the  peritoneal  cavity.  Afanassjew 
likewise  obtained  typical  actinomycosis  by  the  injection  of  pure  cultures  (in 
blood  serum,  agar,  and  bouillon)  into  the  peritoneal  cavity  of  rabbits.  Bos- 
ti'oem  was  unsuccessful  in  his  attempts  to  inoculate  animals  from  man  or 
from  another  animal.  The  actinomyces  colonies,  when  oxygen  is  cut  off, 
form  upon  agar  peculiar  yellowish-white  vegetations  ;  but  when  oxygen  has 
free  access  to  the  colonies  there  are  obtained,  according  to  Bostroem,  char- 
acteristic ochre-coloured  forms  with  a  chalk-like  covering  (Fig.  348).  Pure 
cultures  of  the  actinomyces  gi'ow  upon  blood  serum,  agar-agar,  gh'cerine- 
agar.  and  gelatine,  as  well  as  in  bouillon  ;  growth  upon  potato  takes  place 
more  slowly.     From  what  has  been  said,  it  follows  that  the  actinomyces 


Pig.  347. — Actinomyces  (ray  fungus)  with 
one  branching  "tilament  separated  from 
the  others  (Fonfick). 


!•] 


ACTINOMYCOSIS. 


457 


grows  in  different  ways  according  to  the  nature  of  the  nutritive  medium  and 
the  presence  or  absence  of  oxygen.  It  belongs  to  the  polymorphous  bacteria, 
or  rather  to  the  cladothrix  species,  and  may  occasionally  present  itself  as  a 
simple  rod,  the  above-mentioned  bulbs  being  absent  (Ponfick,  Ziegler,  etc.). 

G.  Hesse  found  in  one  case  of  actinomycosis  a  form  of  fungus  which 
corresponded  neither  to  the  cladothrix  described  by  Bostroem  nor  to  the 
Wo]  if -Israel  micro-organism  of  actinomycosis.  Gr.  Hesse  named  his  fun- 
gus the  cladothrix  liquefaciens,  on  account  of  its  great  jDOwer  for  lique- 
fying blood  serum  and  gelatine.  It  is  obligate  aerobic,  germinates  from 
spherules  or  spores,  and  grows  into  long  filaments  with  branches.  In  the 
stems  of  the  filaments  round  spores  are  developed, 
which  subsequently  come  away,  leaving  behind  the 
empty  stems. 

Outside  of  the  animal  body  the  actinomyces  grows 
by  preference  upon  plants,  particularly  upon  gi'ains 
of  corn. 

The  actinomyces  in  a  section  can  best  be  stained  by  |  «^  j 

Gram's  method,  first  with  methyl  violet,  then  with  Bis-  'i  '  [ 

marck  brown.     Weigert  gives  the  section  a  preliminary  ■;'  ! 

stain  in  orchil  la,  and  then  places  it  in  a  one-per-cent. 
aqueous  solution  of  gentian  violet,  by  which  the  central 
network  of  filaments  is  stained  blue  and  the  bulbous 
periphery  ruby  red. 

Occurrence  of  Aetinomycosis  in  Animals.— Actino- 
mycosis is  observed  particularly  in  cattle,  less  often  in 
swine  and  horses.  By  far  the  most  frequent  site  of  ac- 
tinomycosis is  in  the  jaws  of  cattle.  In  this  situation, 
according  to  Bollinger,  Ponfick,  and  Johne,  hemispheri- 
cal, simple,  or  composite  elevations  and  outgrowths  are 
formed,  particularly  near  the  angle  of  the  lower  jaw. 
They  cause  the  skin  to  become  thin,  finally  break  through 
it,  and  sprout  out  like  a  fungus.  They  have  a  greyish- 
yellow  appearance,  and  are  of  lardaceous  consistency. 
Upon  pressure  pus  escapes,  containing  the  characteristic 
yellow  granules  already  mentioned.  The  latter  usually 
consist  of  a  great  number  of  glandular  formations  cling- 
ing together  like  corals.  The  smallest  elementary  gran- 
ules are  macroscopically  scarcely  visible,  and  reveal  a 
tangle  of  filaments,  as  before  remarked,  which  terminate 
at  the  periphery  in  club-shaped  enlargements  (Fig.  347). 
Microscopically  there  is  usually  observed  in  the  centre 
of  the  nodule  the  actinomyces  gland,  with  its  character- 
istic radiate  or  rather  stellate  arrangement,  surrounded 
by  epithelioid,  lymphoid,  aiid  giant  cells  (Fig.  349). 
The  fungus  has  a  chemotaxic  action,  and  becomes  en- 
capsulated by  leucocytes  and  young  connective-tissue  cells  (Pawlowski,  Mak- 
sutoff).  The  nodules  break  down  later,  and  for  the  most  part  suppurate,  thus 
giving  rise  to  a  correspondingly  extensive  death  of  tissue.  The  growth  of 
the  tumour  is  very  slow ;  the  number  of  the  nodular-shaped  growths  con- 


Fia.  348.— Pure  culture 
(linear  culture)  of  ac- 
tinomrces  upon  agar. 


458  INFLAMMATION   AND   INJURIES. 

stantly  increases,  and,  after  coalescinor  with  one  another,  they  extent!  slowly 
into  the  surrounding  parts.  The  tumours  consist  partly  of  fibrous  connective 
tissue  and  partly  of  granulation  tissue,  and  always  contain  the  characteristic 
small  nodules  or  foci  of  suppuration  with  the  fungous  glands  in  the  form  of 
the  above-mentioned  granules.    The  foci  of  suppuration  are  sometimes  small 

and  sometimes  very  extensive.     In  rare  cases 

o©(S.^^S^'^^  spontaneous  recovery  takes  place  by  cicatricial 

^  W^'^%'^'         contraction  and   calcification.     The  actinoray- 

j^^S^i^/^'-  --     cetes,  which  usually  grow  outside  the  animal 

Q'-''^O^^J0I^SKk^^.k'S^'^^   body  upon   plants,  are  taken  into  the  system 

0  6c^^  ■^^^^^BLS'y  ?^^   mainly  in  the  vegetable  food  ;  but  they  may 

fx     "       ^IfckL  !^r  ^^^^  enter  through  tlie  respiratory  tract  and  any 

J-  ^         ^^^^mP  interruption  of  continuity  in  the  skin.     The  in- 

0  \  fection  is  more  apt  to  occur  in  cattle  living  in 

Q  ^^  ■--,  J  ^  --■  damp  or  marshy  regions,  particularly  dviring  or 

^      ©  ^  soon  after  a  wet  season  (Bostroem).     The  com- 

Fio.  349.— Actinomycosis  of  the      mon  starting-point  of  the  infection  is  the  cavity 

tongue  with  surrounding  eel-      ^f  ^i^^  mouth  (iaw,  tongue,  pharvnx),  and  may 

lular  intiltration,  stained  \vith  ;•*  ,.'.."         '         .      ., 

fuchsin.    X  200.  be  the  result  of  any  slight  injury  to  the  inside 

of  the  mouth  produced  by  stiff  pieces  of  vege- 
table food,  or  by  a  carious  tooth,  etc.  According  to  Johne  and  Bostroem, 
in  most  of  the  tonsils  of  healthy  swine  there  are  found  barley  grains  which 
have  a  fungus  on  their  surface  very  similar  to  the  actinomyces.  In  man, 
also,  infection  is  most  apt  to  originate  from  vegetable  material,  less  often 
from  ingestion  of  actinomycotic  meat  or  milk.  By  growing  into  the  blood- 
vessels the  primary  focus  may  give  rise  to  metastases  in  the  various  organs. 
Metastases  do  not  usually  originate  through  the  lymph  channels. 

Actinomyces  Musculorum  Suis.— The  ray  fungus  occurring  exclusively  in 
the  muscles  of  hogs,  the  so-called  actinomj'ces  musculorum  suis,  discovered 
by  Duncker  in  1884,  is  not  identical  with  the  actinomyces  bovis  s.  homi- 
nis.  Its  radiate  form  is  similar,  but  its  relationship  to  the  actinomyces  bovis 
s.  hominis  is  still  ol)scure. 

Actinomycosis  in  Man. — The  occurrence  of  actinomycosis  in  man  -was 
iirst  carefully  studied  l)y  J.  Israel  in  1885.  He  used  observations  made 
bv  himself,  and  the  thirty-eight  cases  of  the  disease  which  were  then 
to  be  found  in  literature.  The  actinomycosis  of  man  can  be  divided, 
according  to  the  point  of  ingress  of  the  infection,  into  live  groups : 

1.  Cases  in  which  the  fungus  enters  through  the  oral  and  pharyn- 
geal cavities  forming  a  focus  in  carious  teeth,  in  the  inferior  max- 
illa, in  the  submaxillary  and  submental  region,  in  the  neck,  in  the  peri- 
osteum of  the  superior  maxilla,  or  in  the  vicinity  of  the  cheek. 

2.  Cases  of  primary  actinomycosis  of  the  respiratory  apparatus, 
with  localisation  in  the  bronchial  mucous  membrane  and  in  the  paren- 
chyma of  the  lungs,  spreading  to  the  pleura,  the  peripleural,  and  pre- 
vertebral tissues,  or  with  extension  to  the  abdominal  wall,  and  finally 
the  formation  of  metastases. 


5.] 


ACTINOMYCOSIS. 


459 


3.  Cases  of  primary  actinomycosis  in  the  intestinal  tract,  partly  as 
a  superficial  disease  of  the  intestine  and  partly  with  extension  of  the 
process  to  the  peritonaeum  and  abdominal  wall  and  the  formation  of 
metastases. 

4.  Cases  in  which  the  point  of  entrance  is  uncertain  (respiratory 
apparatus,  pharynx,  intestine). 

5.  Infection  in  conjunction  with  an  injury  of  the  skin,  cutaneous 
actinomycosis,  particularly  after  injuries  of  the  skin  inflicted  by  foreign 
bodies  such  as  a  splinter  of  wood,  for  example.     Illich,  counting  in  the 


Fig.  350. — Actinomycosis  of  the  right  side  of  the  neck,  with  numerous  fistulas  leading  to  foci  of 
pus,  surrounded  by  indurated  tissue.    The  patient  is  a  thirty-year-old  peasant.    Eecovery. 

fifty-four  cases  which  he  saw  in  Albert's  clinic,  has  collected  in  all 
four  hundred  and  twenty-one  cases  of  actinomycosis.  Of  these  there 
were  two  hundred  and  eighteen  in  which  the  head  and  neck  were 
affected,  sixteen  of  the  tongue,  fifty-eight  of  the  lungs,  eighty-nine  of 
the  abdomen,  and  eleven  of  the  skin.  In  twenty -nine  cases  the  point 
where  the  infection  entered  could  not  be  proved  with  certainty. 

Actinomycosis  originates  in  man  chiefly  from  parts  of  vegetable 
matter  to  which  the  fungus  clings.  Portions  of  vegetable  matter,  es- 
pecially barley  grains,  have  been  repeatedly  demonstrated  in  the  actino- 
mycotic foci  (Bostroem,  Illich,  etc.).     Infection  by  eating  actinomy- 


460  INFLAMMATION   AND   INJURIES. 

cotic  meat,  or  by  drinking  milk,  is  very  questionable.  The  actinomy- 
cosis of  man  differs  from  that  of  cattle  by  the  smaller  size  of  the  tumours 
and  by  the  preponderance  of  thickening  and  induration  of  the  tissues. 
The  clinical  pictures  of  actinomycosis  in  man  vary  very  much  according 
to  the  primary  location  of  the  disease.  Sometimes  the  phlegmonous 
type  of  inflammation  with  a  suppurative  breaking  down  preponder- 
ates; in  other  cases  the  formation  of  granulations  or  the  induration 
are  most  prominent  {Fig.  350).  The  disease  may  begin  as  a  phleg- 
monous inflammation  about  the  lower  jaw,  forming  epulis-like 
tumours,  especially  when  there  are  carious  teeth  present,  as  in  a  case 
which  I  operated  upon  a  short  time  ago.  The  process  may  ex- 
tend from  the  mouth  or  from  the  jaw  to  the  prevertebral  tissue  of 
the  cervical  and  dorsal  vertebrae  (prevertebral  phlegmon),  with  sec- 
ondary destruction  of  the  vertebrae.  Kot  infrequently  cases  are  ob- 
served which  run  an  acute  course,  presenting  the  picture  of  a  very 
acute  or  even  septic  suppuration,  for  example  in  the  neck,  simulating 
angina  Zudovici  ;  but  this  is  usually  due  to  a  mixed  infection,  as  Partsch 
and  others  have  insisted,  since  the  actinomyces  does  not  by  itself  ex- 
cite suppuration.  Occasionally  actinomycosis  runs  a  course  resem- 
bling chronic  pyaemia,  with  the  formation  of  multiple  abscesses ;  or  the 
disease  begins  in  a  very  insidious  manner,  as  primary  actinomycosis  of 
the  intestine  or  lung,  with  secondary  extension  to  the  peritonaeum, 
heart,  pleura,  and  eventually  the  formation  of  metastases,  etc.  Ab- 
dominal actinomycosis  is  characterised  by  the  formation  of  thick  adhe- 
sions between  the  intestines  and  between  the  latter  and  the  abdominal 
wall,  and  by  abscess  formation  in  the  retroperitoneal  tissues  or  in  the 
abdominal  wall.  The  metastases  may  be  very  numerous,  as  happened 
in  one  case  of  Sonnen burg's,  in  which  the  pleura,  lungs,  the  large  ab- 
dominal organs,  and  the  skin  of  the  thorax,  abdomen,  back,  and  thighs 
were  involved.  The  primary  location  of  the  affection  could  not  be 
determined. 

In  a  pure  actinomycosis  without  any  mixed  infection,  such  as  with 
pus  cocci,  the  lymph  glands  are  usually  not  affected,  and  the  metastatic 
infection  takes  place  not  through  the  lymph  vessels  but  through  the 
general  circulation.  Bollinger  saw  one  case  of  primary  actinomycosis 
of  the  Ijrain  in  a  tweuty-six-year-old  woman  with  bad  teeth,  who  had 
for  a  long  time  drunk  raw  goats'  and  cows'  milk  as  well  as  eaten  raw 
meat.  The  rather  rare  cases  of  isolated  cutaneous  actinomycosis  some- 
times take  the  form  of  cutaneous  ulcers,  and  sometimes  of  nodular 
eruptions  like  tubercular  lupus  (Leser). 

Diagnosis  of  Actinomycosis. — The  above-mentioned  characteristic 
yellow  granules  which  are  found  in  the  pus  or  in  the  granulation  tis- 


§  86.]  ACTINOMYCOSIS.  461 

sue,  as  well  as  the  microscopic  demonstration  of  the  fungus,  are  of 
great  importance  in  making  the  diagnosis. 

Prognosis  of  Actinomycosis. — The  prognosis  depends  mainly  upon 
the  situation  of  the  disease,  and  is  favourable  in  those  cases  in 
which  the  diseased  parts  are  accessible  to  surgical  treatment — for  ex- 
ample, when  they  are  located  in  the  region  of  the  cheeks,  the  jaw, 
the  cavity  of  the  mouth,  the  neck,  etc.  As  Schlange  has  correctly 
remarked,  actinomycosis  has  a  pronounced  tendency  to  get  well  spon- 
taneously— a  fact  which  is  particularly  noticeable  when,  in  actinomy- 
cosis of  the  neck  or  cheek,  the  fungi  have  penetrated  beneath  the  skin 
and  then  are  finally  cast  off  as  foreign  bodies.  The  great  majority  of 
all  cases  of  actinomycosis  which  are  accessible  to  surgical  treatment  can 
be  permanently  cured.  The  prognosis  of  actinomycosis  of  the  internal 
organs  is  very  unfavourable. 

Treatment  of  Actinomycosis. — The  treatment  of  actinomycosis  is 
wholly  surgical ;  it  consists  in  extirpation  or  in  incision  followed  by 
energetic  scraping  out  and  disinfection  of  all  accessible  foci.  In  very 
diffuse  actinomycosis  of  the  skin  antiparasitic  remedies  may  be  used, 
such  as  chrysarobin,  ichthyol,  etc.  Parenchymatous  injections  of  the 
iodide  of  potassium  or  sodium  into  the  actinomycotic  areas  are  use- 
ful in  suitable  cases  (one  to  two  to  five  hypodermic  syringefuls  of  a 
one-per-cent.  solution  at  intervals  of  several  days).  This  may  be  com- 
bined with  the  internal  administration  of  potassium  iodide.  The  acti- 
nomycosis which  is  accessible  to  surgical,  that  is,  to  operative  treat- 
ment— for  example,  actinomycosis  of  the  cheeks,  tongue,  jaw,  the  oral 
cavity,  the  neck,  etc. — always  has  a  favourable  prognosis,  as  remarked 
before,  and  a  permanent  cure  is  generally  obtained,  provided  only  the 
actinomycotic  focus  is  thoroughly  removed.  I  operated  on  a  case  of 
actinomycosis  in  a  young  milkmaid  involving  almost  the  entire  lower 
jaw.  The  loosened  teeth  subsequently  became  perfectly  lirm,  and  the 
restoration  of  the  lower  jaw  was  very  satisfactory.  In  case  of  infec- 
tion of  the  internal  organs,  with  diffuse  foci  located  in  the  thoracic  or 
peritoneal  cavities,  all  treatment  is  usually  unavailing,  and  even  the 
recognition  of  the  disease  may  present  the  greatest  difficulties.  In 
cases  not  suitable  for  operation,  preparations  of  iodine  (iodide  of  potas- 
sium and  of  sodium)  should  be  tried  ;  the  course  of  the  disease  has 
been  favourably  influenced  by  these  in  a  number  of  cases.  Tuberculin 
has  also  been  employed  with  varying  results. 


CHAPTER   II. 

INJURIES    AXD    SURGICAL   DISEASES    OF   THE    SOFT    PARTS. 
(skin,  cellular  tissue,  mucous  membraxes,  blood-vessels,  lymphatic  system, 

NERVES,  muscles,  TENDONS,  TENDON  SHEATHS,  BURSiE.) 

Wounds  of  the  soft  parts  (incised  wounds,  punctured  wounds  [phlebotomy],  contused 
and  lacerated  wounds).— Treatment  of  wounds  of  the  soft  parts  (htemostasis,  tenor- 
rhaphy, neurorrhaphy  [muscle-  and  nerve-regeneration],  suture  of  a  wound,  dress- 
ing).— Treatment  of  the  conditions  following  severe  loss  of  blood  (transfusion, 
salt  infusion). — Burns;  sunstroke:  injuries  from  lightning;  congelation;  gunshot 
wounds  of  soft  parts  ;  of  bones  and  joints. — Subcutaneous  injuries  of  soft  parts 
(contusion  ;  subcutaneous  rupture  of  tissue ;  muscular  hernia ;  dislocation  of  ten- 
dons and  nerves). — Inflammations  and  diseases  of  the  soft  parts  (skin,  cellular  tis- 
sue, mucous  membranes,  arteries,  veins,  lymphatic  system,  nerves,  muscles,  tendon 
sheaths,  bursfe). — Gangrene  of  the  soft  parts. 

§  87.  "Wounds  of  Soft  Parts. — Of  the  various  kinds  of  wounds,  the 
simple  incised  wounds  are  the  ones  which  present  most  clearly  for  the 
beginner  the  symptomatology  of  wounds  of  soft  parts,  and  hence  we 
shall  begin  with  them. 

Symptomatology  of  WoTuids,  particularly  Incised  Wounds. — The  chief 
symptoms  revealed  by  every  wound  are  pain,  haemorrhage,  and  gaping 
of  the  edges. 

Wound  Pain. — Tlie  degree  of  jDain  from  a  wound  varies  with  the 
peculiarities  of  the  individual,  the  portion  of  the  body  affected,  and  the 
nature  of  the  injury.  Every  one  knows  that  the  susceptibility  to  pain 
manifested  by  different  people  is  very  variable.  As  regards  the  loca- 
tion of  the  injury,  wounds  of  the  fingers,  lips,  nose,  the  external  geni- 
tals, and  bone  are  particularly  painful.  The  division  of  a  sensory  or 
mixed  peripheral  nerve  is  accomjDanied  by  overpowering  pain,  while 
division  of  the  white  matter  of  the  brain,  in  s]3ite  of  the  numerous 
nerve  fibres  it  contains,  causes  no  pain  to  speak  of.  If  the  division  of 
the  tissues  is  done  rapidly  with  a  sharp  instrument,  the  sensation  of  jDain 
is  less  than  when  it  is  done  slowly  and  with  blunt  instruments.  Con- 
sequently it  is  best,  particularly  in  patients  who  are  not  chloroformed, 
to  operate  with  a  sharp  knife,  and  to  divide  the  skin,  with  its  rich 
supply  of  nerves,  rapidly  by  a  single  stroke.  In  gun-shot  wounds  the 
tissues  are  divided  so  quickly  that  the  pain  is  often  slight. 
462 


§  87.]  WOUNDS   OF   SOFT   PARTS.  463 

The  subjective  feeling  of  pain  accompanying  the  injury  is  less  im- 
portant for  the  physician  and  has  less  bearing  upon  the  treatment  than 
the  other  objective,  perceptible  symptoms — the  haemorrhage  and  the 
gaping  of  the  margins  of  the  wound. 

Gaping  of  the  Wound. — The  gaping  of  the  wound — that  is,  the 
separation  of  the  divided  soft  parts — is  caused  by  the  tension  and  elas- 
ticity of  the  tissues  and  by  the  contractility  of  the  muscular  elements. 
Hence  it  is  natural  for  the  skin,  fascia,  tendons,  muscles,  vessels,  nerves, 
etc.,  after  being  divided,  particularly  if  in  a  transverse  direction,  to  be 
pulled  asunder. 

Haemorrliage. — The  hsemorrhage  (extravasation)  is  the  most  impor- 
tant manifestation  in  the  wound.  In  every  division  of  tissue,  lymph, 
in  addition  to  blood,  is  poured  out  of  the  divided  lymph  spaces  and 
lymph  vessels ;  but  the  outflow  of  lymph  is  arrested  partly  by  coagu- 
lation and  partly  by  even  a  very  slight  resistance  in  the  wound,  as  the 
amount  of  pressure  in  the  lymphatic  vessels  is  very  small,  being  no 
greater  than  in  the  surrounding  tissues.  Besides  the  blood  and  the 
lymph,  when  injuries  involve  such  structures  as  glands,  joints,  etc., 
there  may  be  an  escape  of  the  fluid  peculiar  to  these  organs,  such  as 
glandular  secretion,  synovia,  etc. 

We  are  mainly  interested  in  the  extravasation  of  blood  from  the 
vessels — haemorrhage.  This  is  either  arterial,  venous,  or  capillary — 
i.  e.,  parenchymatous. 

Arterial  Haemorrhage. — Arterial  haemorrhage  is  characterised  by 
bright-red  blood  which  spurts  in  a  smaller  or  larger  stream  from  the 
injured  vessel,  "When  there  is  danger  of  asphyxia,  the  colour  of  the 
arterial  blood  is  not  bright  red  but  dark  red,  like  venous  blood ;  in- 
deed, in  bad  cases  of  asphyxia,  shortly  before  death,  the  blood  has  a 
remarkably  dark-red  or  even  an  actually  black  colour.  Under  such 
conditions,  as  a  result  of  the  threatening  cardiac  paralysis,  the  blood 
pressure  in  the  arterial  system  is  so  lowered  that  the  blood  does  not 
spurt  forth  in  jets,  but  flows  more  continuously  or  suddenly  ceases 
entirely,  as  we  have  described,  for  example,  on  page  30,  in  case  of 
threatened  death  from  chloroform.  The  bleeding  from  small  arteries 
usually  ceases  of  its  own  accord  from  retraction  and  contraction  of  the 
arterial  walls  and  from  the  pressure  of  the  surrounding  tissues.  In 
larger  arteries  the  bleeding  does  not  stop  of  itself,  and  the  injured 
person  bleeds  to  death  unless  the  haemorrhage  is  arrested  by  artificial 
means.  The  amount  of  the  haemorrhage  depends,  of  course,  when  the 
artery  is  entirely  divided,  upon  the  size  of  the  vessel,  and,  when  par- 
tially divided,  upon  the  size  of  the  opening  in  the  wall  of  the  vessel. 
Longitudinal  wounds  of  an  artery  are  not  so  dangerous  as  transverse 


464:    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT   PARTS. 

ones,  as  the  latter  gape  more,  and  consequently  render  spontaneous 
arrest  of  the  hfemorrhage  difficult.  A  transverse  division  of  a  large 
artery,  such  as  the  common  carotid,  the  brachial,  or  femoral,  will  be 
followed  by  death  from  loss  of  blood  in  a  short  time,  except  in  the  case 
of  punctured  wounds,  or  in  contused  and  lacerated  wounds.  In  con- 
tused and  lacerated  wounds,  even  in  those  resulting  from  tearing  away 
an  extremity,  the  hemorrhage  may  be  very  slight.  The  contused  and 
lacerated  vessels  are  crushed,  and,  in  the  case  of  arteries,  the  media  and 
intima  are  rolled  inwards,  while  the  adventitia  is  likewise  twisted  or 
pressed  together ;  hence  the  bleeding  is  only  slight.  But  in  all  con- 
tused wounds  secondary  haemorrhage  very  frequently  occurs  when  the 
contused  portion  of  the  vessel  or  the  thrombus  separates.  Secondary 
haemorrhage  also  readily  results  from  punctured  wounds  of  arteries 
which  have  been  closed  by  a  temporary  contraction  of  the  elastic  arte- 
rial wall  or  by  a  blood-clot. 

Hsemorrliage  from  the  Veins. — In  haemorrhage  from  the  veins  the 
dark-red  blood  flows  out  more  continuously,  and  when  a  vein  is  com- 
pletely divided  it  flows  most  freely  from  the  peripheral  end.  In  large 
veins,  when  the  valves  are  insufficient,  or  when  in  the  neighbourhood 
of  the  injury  large  branches  open  into  the  main  vein,  the  blood  flows 
backwards  out  of  the  central  end.  Under  these  conditions  haemor- 
rhage takes  place  from  both  ends  of  the  divided  vein.  Haemor- 
rha^e  from  the  large  veins  in  the  neighbourhood  of  the  trunk  is  par- 
ticularly dangerous  to  life  if  aid  is  not  at  hand  ;  the  dark-red  blood 
usually  wells  forth  in  great  quantities.  But  patients  have  occasionally 
bled  to  death  even  from  varicose  veins  of  the  leg.  The  reasons  for 
such  severe  haemorrhage  are  that  the  return  flow  of  venous  blood  from 
the  dilated  veins  of  the  leg  is  rendered  difficult  by  the  dependent  posi- 
tion of  the  veins  and  by  the  partial  obliteration  of  the  venous  channels 
by  previous  inflammatory  thrombi,  and  that  the  patients  often  have 
absolutely  no  idea  of  how  to  help  themselves.  Under  such  circum- 
stances, instead  of  elevating  the  leg  and  compressing  the  wound  with 
the  finger,  they  use  the  strangest  kind  of  methods  for  arresting  haem- 
orrhage. 

Haemorrhage  from  Capillaries. — The  haemorrhage  from  the  capil- 
laries and  small  veins  usually  ceases  spontaneously  in  consequence  of 
the  retraction  of  their  walls,  and  particularly  because  of  the  coagulation 
of  the  blood  (see  page  296).  It  is  well  known  that  the  blood  which 
leaves  the  vascular  passage  coagulates,  and  a  blood-clot,  a  so-called 
thrombus,  forms  in  the  wound  in  the  vessel  (see  page  296),  which 
not  only  shuts  off  the  communication  of  the  vessel  with  the  exterior, 
but  also  extends  for  some  distance  into  its  lumen.     In  this  wav  the 


§87.]  WOUNDS   OF  SOFT   PARTS.  465 

hnemorrhage  ceases,  provided  the  blood-clot  is  not  washed  away  hj  the 
blood  current.  The  thrombosis  takes  place  the  more  rapidly  and  cer- 
tainly the  less  the  blood  pressure  is  in  the  vessels,  particularly  the 
capillaries  and  small  veins.  But  the  spontaneous  closure  by  a  throm- 
bus of  a  wound  in  an  artery  or  large  vein  which  is  adherent  to  the  sur- 
rounding parts  is  difficult  or  even  impossible. 

The  Results  of  a  Great  Loss  of  Blood. — After  a  great  loss  of  blood 
there  follows  a  falling  off  of  the  arterial  pressure  and  a  cardiac  weak- 
ness whereby  thrombus  formation  is  facilitated.  A  severe  haemor- 
rhage is  thus,  in  itself,  more  or  less  haemostatic  in  its  effects.  In  the 
same  way  haemorrhage  is  much  diminished  by  transitory  heart  weak- 
ness during  a  fainting  spell,  even  when  due  to  psychic  influences.  As 
a  result  of  severe  haemorrhage  the  blood  itself  is  changed.  It  becomes 
richer  in  colourless  corpuscles,  which  flow  out  of  the  vessels  of  the 
smallest  calibre  where  they  had  accumulated,  and  the  lymph,  with  the 
lymph  corpuscles,  also  streams  with  greater  rapidity  and  in  greater 
quantities  into  the  depleted  vascular  system.  Under  these  circum- 
stances the  coagulability  of  the  blood  increases,  and  this  again  facili- 
tates the  spontaneous  arrest  of  haemorrhage.  If  a  dog  is  bled  to  death 
by  repeated  phlebotomies,  the  blood  last  taken  from  the  animal  will 
often  coagulate  almost  immediately. 

Further  Manifestations  Following  Severe  Loss  of  Blood. — The  further 
symptoms  following  severe  loss  of  blood  consist  in  pallor  and  cold- 
ness of  the  skin  particularly  that  of  the  face  and  the  extremities,  in 
great  weakness,  spots  before  the  eyes,  ringing  in  the  ears,  nausea 
vomiting,  a  feeling  of  anxiety,  vertigo,  fainting  attacks,  etc.  The 
certain  precursors  of  rapidly  approaching  death  from  loss  of  blood  are 
severe  dyspnoea,  stoppage  of  the  glandular  secretions,  loss  of  conscious- 
ness, dilatation  of  the  pupils,  involuntary  evacuation  of  urine  and 
faeces,  convulsions  which  are  excited  by  sensory  irritation,  such  as  a 
needle-prick,  etc.  The  high  grade  of  dyspnoea  and  the  convulsions 
preceding  death  from  haemorrhage  are  a  result  of  the  rapid  impoverish- 
ment of  the  brain  in  oxygen,  such  as  occurs  in  strangulation  (Rosenthal). 
The  same  set  of  symptoms,  it  is  well  known,  make  their  appearance  in 
the  Kussmaul-Tenner's  experiment,  when  by  occlusion  of  the  carotid 
and  vertebral  arteries  an  acute  cerebral  anaemia  is  excited,  or  when  the 
return  flow  of  the  venous  blood  is  suddenly  interrupted. 

Powers  of  Withstanding  Loss  of  Blood.— The  power  of  withstand- 
ing loss  of  blood  appears,  to  a  certain  extent,  to  be  subject  to  individ- 
ual variations.  After  severe  loss  of  blood  every  surgeon  has  seen  in 
a  relatively  short  time — two  to  three  days — threatening  symptoms 
vanish  in  cases  where  he  expected  certain  death ;  and  again,  on  the 
33 


466    INJURIES  AND   SURGICAL   DISEASES   OF   THE   SOFT   PARTS. 

other  hand,  some  patients  go  into  collapse  after  the  loss  of  very  little 
blood.  Very  young  children  may  he  endangered  by  an  insignificant 
hseraorrhage,  and  weakly  children  a  year  old  have  died  after  a  loss  of 
only  t\yo  hundred  and  fifty  grammes  of  blood.  In  strong  adults,  who 
are  otherwise  healthy,  the  loss  of  half  the  total  amount  of  blood  is  sure 
to  be  fatal.  "Women  appear  to  stand  loss  of  blood  better  than  men.  The 
formation  of  new  blood  seems  to  take  place  more  easily  and  rapidly  in 
them  on  account  of  the  periodic  replacement  of  the  blood  lost  in  eyery 
menstruation  (Landois).  Fat  people  and  old  and  weak  individuals  are 
very  susceptible  to  loss  of  blood.  The  more  rapidly  the  haemorrhage 
takes  place  the  more  dangerous  it  is. 

Death  from  Haemorrhage  observed  in  Experiments  on  Animals.— In  gen- 
eral, the  facts  which  we  have  ascertained  by  bleeding  dogs  to  death  experi- 
mentally are  also  applicable  to  man.  As  much  as  a  quarter  of  their  total 
normal  quantity  of  blood  has  been  withdrawn  from  dogs  by  phlebotomy 
without  causing  the  blood  pressure  in  the  arteries  to  sink  permanently. 
During  the  phlebotomy  the  arterial  pressure,  of  course,  falls  off  rapidly,  and 
the  pulse  becomes  small.  But  very  soon,  even  in  a  few  minutes,  the  pulse 
again  becomes  stronger,  the  blood  pressure  rises,  not  because  the  contents 
of  the  vascular  system  have  correspondingly  increased,  but  simply  for  the 
reason  that  the  arteries  contract  in  consequence  of  the  ii'ritation  of  the  vaso- 
motor  centre  in  the  medulla  oblongata  produced  by  the  anaemia,  and  thus 
accommodate  themselves  to  the  diminished  amount  of  blood  they  contain 
(Landois).  The  antemia  caused  by  the  loss  of  blood  acts  as  a  stimulant  to 
the  centre  of  the  vasomotor  nerves.  It  overcomes  the  transitory  fall  in 
pressure  following  the  loss  of  a  certain  quantity  of  blood  which  is  within  the 
above-mentioned  limit.  The  rapidity  with  which  the  blood  flows  and  the 
frequency  of  the  cardiac  contractions  remain  the  same  as  before  the  haemor- 
rhage. But  if  more  than  a  quarter  of  its  contents  is  withdrawn  from  the 
vascular  system — a  third,  for  example — the  ai'terial  pi'essure  does  not  again 
rise,  but  remains  lowered,  the  rapidity  of  the  current  decreases,  and  the  con- 
traction of  the  heart  becomes  slower  in  consequence  of  the  incomplete  filling 
of  the  ventricle.  But  as  the  vagus  centre  receives  less  stimulation  in  conse- 
quence of  the  diminished  arterial  pressure,  the  frequency  of  the  pulse  is  usu- 
ally accelerated  (Cohnheim).  At  the  same  time,  a  change  takes  place  in  the 
composition  of  the  blood,  the  water  it  contains  being  increased  by  absorption 
of  the  parenchymatous  liquids  and  by  the  accelerated  flow  of  the  lymph  from 
the  thoracic  duct.  As  a  result  of  the  lowered  blood  pressure  the  contents 
of  the  capillaries  do  not  transude  any  longer  from  within  outwards,  but  the 
reverse  condition  j)revails  :  there  ensues  a  diffusion  and  absorption  from  with- 
out inwards  (Cohnheim). 

In  man,  a  loss  of  blood  amounting  to  about  one  half  of  the  total  nor- 
mal quantity  always  proyes  fatal;  but  even  a  moderate  loss,  amount- 
ing to  a  quarter  of  the  total  quantity,  would  give  lise  to  serious  dangers 
for  the  organism  in  a  short  time,  unless  the  blood  lost  were  replaced 


§87.]  WOUNDS  OP  SOFT  PARTS.  467 

by  a  corresponding  regeneration  of  blood.  Tbe  bsemorrhages  which 
are  difficult  to  stop  and  occur  in  bleeders,  as  they  are  called  (see  pages 
62-65),  are  especially  dangerous. 

Regeneration  of  the  Blood  after  a  Haemorrhage.— If  the  bleeding  does  not 
go  on  to  death  the  blood  is  restored  by  absorption  from  the  tissues  or  from 
the  food  taken  in,  the  first  to  be  absorbed  being  the  serum  sanguinis,  with  the 
dissolved  salts,  and  then  the  albumen.  A  longer  time  is  required  to  form 
new  red  blood-corpuscles.  The  great  thirst  following  profuse  haemorrhage 
is  characteristic.  The  patients  eagerly  drink  great  quantities  of  water.  The 
regenerated  blood  is  at  fii'st  abnormally  watery  (hydrsemic)  and  poor  in  cells 
(oligocythaemia,  hypoglobulous).  As  a  result  of  the  greater  flow  of  lymph 
into  the  blood  the  number  of  the  white  blood-corpuscles  is  greatly  increased, 
and  then  their  amount  falls  off ;  the  red  blood-corpuscles  again  attain  their 
usual  number,  and  the  composition  of  the  blood  gradually  returns  to  the 
normal.  We  do  not  as  yet  know  certainly  how  the  restoration  of  the  red 
blood-corpuscles  takes  place.  The  most  generally  accepted  view  is  that  col- 
ourless corpuscles  are  being  constantly  formed  in  the  lymph  glands,  in  the 
spleen,  the  bone  marrow,  and  in  the  liver,  and  a  certain  number  of  these 
colourless  corpuscles  change  into  the  red  disks  (Neumann,  Erb).  After  mod- 
erate losses  of  blood  in  animals,  Buntzen  saw  the  volume  of  the  blood 
restored  in  a  few  hours,  and  when  the  loss  was  severe,  within  twenty-four  to 
forty-eight  hours.  The  red  blood-corpuscles,  after  haemorrhages  amounting 
to  from  1.1  to  4.4  per  cent,  of  the  body  weight,  were  again  complete  after  the 
lapse  of  seven  to  thirty-four  days.  The  beginning  of  the  regeneration  was 
proved  to  take  place  after  forty-eight  hours. 

Entrance  of  Air  into  the  Veins. — Among  the  dangers  which  may 
follow  an  injury  to  a  vein,  particular  mention  should  be  made  of  the 
entrance  of  air  into  the  vein,  a  matter  which  we  discussed  on  page  65. 

Of  the  other  symptoms  caused  by  wounds,  those  are  of  especial 
importance  which  indicate  division  of  the  muscles,  tendons,  and  nerves, 
or  the  opening  of  a  joint  or  a  cavity  of  the  body.  I  shall  refer  to  the 
latter  complications  under  Injuries  of  Joints,  and  in  the  Text-Book  on 
Regional  Surgery  (injuries  of  the  cranial  cavity,  thorax,  and  abdomen, 
and  of  the  separate  joints). 

Division  of  Muscles  and  Tendons. — The  symptoms  which  indicate  a 
division  of  muscles  and  tendons  are  very  simple ;  they  consist  in  dis- 
turbance of  the  function  of  the  afEected  muscle,  and,  in  addition,  the 
divided  muscles  and  tendons  can  usually  be  seen  at  once  when  the 
incised  wound  is  carefully  inspected. 

Division  of  the  Nerves. — The  symptoms  following  division  of  the 
peripheral  nerves  (we  omit  incomplete  divisions,  contusions,  and 
punctures  of  nerves)  consist  likewise  in  a  corresponding  functional 
disturbance  of  the  affected  peripheral  nerve — in  other  words,  in  sen- 
sory and  motor  disturbances. 


4,eS    INJURIES   AND  SURGICAL   DISEASES   OF   THE   SOFT   PARTS. 

Degeneration  of  Nerve  Fibres  cut  off  from  their  Centres.— Nerve  fibres 
cut  otf  truiu  their  cuimectioii  with  the  central  nervous  system  after  a 
time  lose  their  excitability ;  they  undergo  a  fatty,  granular  degenera- 
tion, wliich  involves  the  entire  separated  portion  of  the  nerve  down  to 
its  finest  peripheral  branches  (Miiller,  Waller).  The  sensory  fibres, 
according  to  Waller,  degenerate  not  in  the  peripheral  but  in  the  cen- 
tral portion  when  the  posterior  root  is  cut  above  the  spinal  ganglion. 
The  spinal  ganghou  consequently  plays  the  same  part  in  the  preserva- 
tion of  the  sensory  fibres  that  the  spinal  cord  does  for  the  motor.  The 
paralytic  degeneration  probably  occurs  simultaneously  in  the  whole 
length  of  the  peripheral  portion,  not  spreading  from  the  point  of  sec- 
tion towards  the  periphery,  nor  beginning,  as  Schiff  describes  it,  in  the 
peripheral  network.  The  contents  of  the  nerve  finally  disappear  com- 
pletely, and  probably  the  empty  neurilemma  also.  The  connective 
tissue  of  the  nerves  is  the  seat  of  an  inflammatory,  nuclear  prolifera- 
tion. There  is  still  a  division  of  opinion  as  to  whether  or  not  the 
degeneration  likewise  involves  the  peripheral  end  organs,  such  as  the 
tactile  corpuscles,  the  rods  of  the  retina,  the  terminations  of  the  ol- 
factory nerves,  etc.  Kecently  F.  Krause  has  carefully  studied  the 
ascending  and  descending  degeneration  of  divided  nerves,  and  he  states 
that  all  the  sensory  fibres  in  the  peripheral  segment  of  the  nerve 
which  are  connected  with  a  trophic  centre  in  the  periphery,  such  as 
Meissner's  tactile  corpuscles,  remain  intact,  but  the  central  segment  of 
the  nerve  undergoes  degeneration.  On  the  other  hand,  all  the  motor 
nerve  fibres  and  the  sensory  fibres  of  the  bones,  periosteum,  joints, 
muscles,  tendons,  and  the  sensory  fibres  terminating  free  in  the  skin 
persist  in  the  central  nerve  segment  and  degenerate  in  the  peripheral 
portion  of  the  nerve.  At  the  same  time  that  these  degenerative  pro- 
cesses are  taking  place  in  the  nerves,  the  muscles  atrophy  and  in  part 
undergo  fatty  degeneration. 

The  disturbances  of  sensation  after  division  of  nerves  are  not  so 
pronounced  as  the  motor- paralytic  manifestations.  If,  for  example,  a 
mixed  nerve  in  the  extremities — such  as  the  median  or  ulnar — is  di- 
vided, the  manifestations  of  motor  paralysis  are  always  exhibited  in  a 
typical  manner,  while  the  sensory  paralysis  may  he  very  slight  or  almost 
completely  absent,  because  the  collateral  anastomoses  of  the  neighbour- 
ing uninjured  nerves  take  up  vicariously  the  conduction  of  the  sensory 
impulses.  There  is  an  intimate  anastomosis  between  the  finer  nerve 
branches  in  the  skin,  particularly  upon  the  fingers,  and  in  the  face. 
The  individual  perceptive  senses  appear  to  behave  differently  after 
injuries.  It  sometimes  happens  that  all  the  senses — that  is,  the  tactile, 
temperature,  and  pain  sense — are  lost  after  division  of  a  nerve,  or  they 


§87.]  WOUNDS   OF  SOFT   PARTS.  469 

are  more  or  less  retained ;  in  still  other  cases  only  the  tactile  sense 
persists  while  the  pain  and  temperature  senses  are  suspended.  Imme- 
diately after  the  injury  the  disturbances  of  sensibility  are  most  pro- 
nounced, and  after  four  to  six  days  the  manifestations  of  sensory 
paralysis  improve  without  its  necessarily  following  that  a  regeneration 
of  the  nerve  has  occurred  at  the  injured  point.  Indeed,  the  disturbance 
of  sensibility  may  disappear  more  or  less  completely,  though,  in  fact, 
no  union  has  taken  place  between  the  divided  ends  of  the  nerve.  The 
collateral  paths  gradually  take  on  more  and  more  activity,  or  new- 
formed  nerve-fibres  grow  from  the  uninjured,  collateral  nerves  into 
the  anaesthetic,  cutaneous  district. 

As  regards  the  motor  disturbances,  the  muscles  supplied  by  any 
particular  motor  or  mixed  nerve  are  always  paralysed  after  division  of 
this  nerve.  The  position  of  the  hand — for  instance,  after  division  of 
the  musculo-spiral,  median,  or  ulnar  nerve,  is  always  a  typical  one  (see 
Regional  Surgery).  Yariations  from  the  general  rule  of  course  may 
occur  when  there  are  anomalies  in  innervation.  There  is  observed, 
however,  after  nerve  division,  especially  in  the  subsequent  course  of 
the  case,  more  or  less  substitution  in  the  sense  that  other  muscles,  sup- 
plied by  an  uninjured  nerve,  perform  singly  or  in  groups  the  duties 
of  the  paralysed  muscles.  According  to  Letievant,  these  substitutions 
may  act  so  perfectly,  when  occurring  between  the  ulnar  and  median 
nerves,  for  example,  that  it  is  possible  on  superficial  examination  to 
overlook  an  actually  existing  paralysis  of  the  parts  supplied  by  the 
divided  nerve.  Kiister  and  Falkenheim  have  described  analogous 
cases.  If,  after  division  of  a  mixed  or  motor  nerve,  paralysis  is  par- 
tially or  entirely  absent,  the  cause  is  to  be  ascribed,  according  to  ob- 
servations made  upon  such  cases  by  Kraussold,  Spillman,  and  others,  to 
anomalies  of  innervation  or  to  the  persistence  of  undivided  collateral 
nerve  filaments  which  connect  the  central  and  peripheral  stump  of  the 
divided  nerve.  The  further  towards  the  centre  a  motor  or,  rather, 
mixed,  nerve  is  divided,  so  much  the  more  extensive  are,  of  course,  the 
symptoms  of  motor  paralysis. 

Of  the  other  symptoms  which  follow  division  of  peripheral  nerves 
I  should  briefiy  mention  the  following :  Yery  frequently,  indeed 
almost  always,  the  patients  after  division  of  a  nerve  complain  of  a 
marked  sensation  of  cold  in  the  paralysed  district,  Hutchinson  states 
that  the  difference  in  temperature  amounts  to  from  2.2°  to  5°  C.  (tl:°  to 
9°  F.).  Kraussold  and  Rohden  found  that  the  temperature  in  the 
paralysed  parts  after  division  of  the  ulnar  nerve  was  lowered  as  much 
as  6°  to  9.8°  C.  (10.8°  to  17°  F.).  In  rare  cases  the  temperature  in  the 
paralysed  parts  has  been  observed  to  be  elevated  2°  to  5°  C.  (3.6°  to 


470    INJURIES  AND  SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

9°  F.)  (Ilajm).  Other  nianifestations  are  a  burning,  prickling  pain, 
formication,  an  increase  in  the  secretion  of  sweat  or  a  remarkable  dry- 
ness of  the  involved  area  of  skin,  and,  finally,  cutaneous  affections 
such  as  herpes  zoster,  eczema,  pemphigus,  ecthyma  pustules,  disturb- 
ances in  the  nutrition  of  the  skin,  such  as  the  formation  of  eschars, 
ulceration,  or  gangrene,  especially  on  the  finger-tips.  The  skin  is 
cedematous,  bluish  red,  or  abnormally  pale.  In  the  periosteum  and 
bones  inflammatory  and  trophic  disturbances  are  also  observed.  In 
the  joints  there  are  serious  effusions  taking  the  form  of  chronic  hy- 
drarthrosis or  subacute  articular  rheumatism,  adhesive  joint  inflam- 
mations, now  and  then  terminating  in  a  stiff"  joint — anchylosis.  The 
neuroparalytic  (neuropathic)  joint  disturbances,  resembling  a  subacute 
articular  rheumatism,  lead  to  a  painful  swelling  of  the  joint,  and  finally 
to  distention  and  subluxation  of  the  articular  surfaces,  to  marked  atro- 
phy of  the  bone,  and  to  destruction  of  the  whole  joint.  All  of  the 
last-mentioned  changes  in  the  bones  and  joints  occur  only  as  the  final 
results  following  an  unhealed  division  of  a  nerve.  After  the  paralysis 
has  lasted  some  time  a  progressive  atrophy  of  the  portion  of  the  body 
in  question  takes  place  not  only  in  the  muscles  and  the  soft  parts  but 
also  in  the  bones.  The  electrical  excitability  of  the  divided  nerves  and 
muscles  decreases  by  degrees,  and  finally  is  lost  entirely. 

I.  Punctured  Wounds. — Punctured,  contused,  and  lacerated  wounds 
present  many  peculiarities,  and  it  is  therefore  necessary  to  study  them 
somewhat  more  in  detail. 

Punctured  wounds  are  produced  by  sharp  or  blunt-pointed  instru- 
ments, such  as  swords,  daggers,  knives,  needles,  spHnters  of  glass  or 
wood,  etc.  Arrow  wounds  of  the  Indians,  for  example,  are  described 
in  §  82.  Punctured  wounds  belong,  in  the  majority  of  cases,  to  simple 
wounds,  and  heal  comparatively  quickly  if  the  injury  does  not  involve 
deeply  lying  parts,  such  as  vessels,  nerves,  joints,  or  the  large  cavities 
of  the  body  with  their  contents,  including  the  cranial  cavity,  the  pleural 
or  peritoneal  cavities.  Sharp-pointed  instruments  in  general  produce 
punctured  wounds  with  smooth  borders,  while  blunt-pointed  objects  are 
more  apt  to  contuse  the  borders  of  the  wound.  Punctured  wounds,  as 
a  general  thing,  correspond  in  shape  to  the  instrument  by  which  the 
wound  was  produced — a  fact  which  is  of  especial  importance  in  medical 
jurisprudence. 

In  a  great  number  of  punctured  wounds  the  depth  of  the  wound  is 
disproportionately  great  in  comparison  to  its  length  and  -v^ddth,  and  the 
nature  of  the  injury  is  not  so  apparent  as  in  incised  wounds.  If  large 
arteries  or  veins  have  been  injured,  the  haemorrhage  which  appears 
externally  may  be  relatively  slight.     If  a  large  artery  is  punctured,  at 


§87.] 


WOUNDS  OF   SOFT  PARTS. 


471 


the  moment  of  the  injury  a  great  bright-red  stream  of  blood  spurts 
out ;  but  after  removal  of  the  instrument  only  a  little  blood  trickles 
from  the  wound,  because  the  puncture  in  the  artery  has  been  closed  by 
the  elasticity  of  the  arterial  wall.  Should  the  haemorrhage  continue 
from  the  artery,  it  does  not  appear  externally,  but  takes  place  into  the 
tissues  surrounding  the  vessel,  because  the  soft  parts  divided  by  the 
puncture  fall  together  again,  and  do  not  permit  the  blood  to  escape  to 
the  surface  of  the  body.  Under  such  conditions  a  large  blood  tumour 
forms,  a  so-called  traumatic  aneurysm,  in  contradistinction  to  the  true 
aneurysm,  which  is  a  more  gradually  developing,  sacculated,  or  spin- 
dle-shaped dilatation  of  an  artery.  In  the  traumatic  aneurysm  there  is 
heard,  upon  auscultation  with  the  stethoscope  over  the  blood  tumour 
and  so  over  the  point  of  injury,  a  systolic  hruit  or  murmur  isochronous 
with  the  pulse,  caused  by  the  outflow  of  the  blood  through  the  opening 
in  the  artery  into  the  surrounding  tissues.  This  systolic  murmur,  fol- 
lowing a  puncture  in  an  artery,  ceases  immediately  when  the  artery 
involved  is  compressed  above  the  point  of  injury  or  when  the  hole  in 
the  vessel  becomes  closed  by  a  thrombus.  ~^o  sound  is  heard,  however, 
when  the  artery  is  cut  completely  across.  These  murmurs  are  of  great 
diagnostic  importance. 

Punctured  Wounds  involving  a  Vein  and  Artery. — If  an  artery  and  a 
vein  are  injured  simultaneously  by  a  puncture  (as  may  occur,  for  exam- 
ple, in  phlebotomy  when  the  point  of  the  knife  is 
stuck  too  deeply  into  the  median  basilic  vein  and  //////^J 

penetrates  the  brachial  artery  lying  under  the  vein), 
there  may  result  a  permanent  communication  be- 
tween  the  artery  and  the  vein ;   a  sac  is  formed 


Tig.  351. — Aneurysma  arterio-venosum  {A)  at  the  bend  of  the  elbow 
resultino'  from  venesection  ;  h,  arteria  brachialls  (Bell).  The  sac 
A  of  the  aneurism  is  laid  open  (Froriep). 


Fig.  352. — Aneurys- 
ma arterio-veno- 
sum (Busch). 


(Figs.  351,  352),  into  which  flows  the  blood  of  the  artery  as  well  as 
that  of  the  vein.  This  condition  is  called  aneurismal  varix,  or  varicose 
aneurism,  or,  better  still,  arterio-venous  aneurism. 


Vena  cephal. — 

N.  cutan.  ext. 


Vena  medio- 
basilica  s.  me- 
dianaobliqua. 


472    INJURIES  AND  SURGICAL   DISEASES  OF  THE   SOFT   PARTS. 

Technique  of  Phlebotomy,  or  Venesection.— This  is  i)erhaps  the  best  place 
for  brielly  considering  blood-letting.  Venesection,  or  phlebotomy,  formerly 
much  used  for  all  sorts  of  diseases,  is  at  present  almost  never  done  in  surgical 
practice.     Phlebotomy  is  performed  almost  exclusively  on  the  veins  of  the 

elbow,  particulai'ly  the 
median  basilic,  which  is 
generally  the  best  de- 
veloped (Fig.  .353).  It  is 
to  be  noted  that  the  me- 
dio-basilic  vein  crosses 
the  bi'achial  artery,  and 
at  this  point  is  only  sep- 
arated from  it  bj'  the 
very  thin  aponeurosis 
of  the  biceps  muscle; 
consequently  before  the 
operation  it  is  best  to 
feel  for  the  pulsation  of 
the  artery,  and  to  open 
the  vein  either  above  or 
below  the  point  where 
they  cross.  In  order  to 
avoid  subsequent  neu- 
ralgia the  middle  and 
external  cutaneous  nerves  (Fig.  353)  should  not  be  injured.  Phlebotomy  is 
performed  in  the  following  manner :  In  the  first  place,  the  middle  of  the 
(upper)  arm  is  encircled  by  a  bandage,  or  piece  of  folded  cloth,  to  produce 
venous  stasis  and  distention  of  the  vein.  The  tourniquet  should  not  be 
applied  so  tightly  as  to  close  the  artery  ;  the  radial  pulse  must  therefore  per- 
sist. The  arm  should  hang  down,  to  permit  a  more  complete  filling  of  the 
vein.  The  vein  is  best  opened  with  a  pointed  scalpel  after  the  field  of  opera- 
tion has  been  carefully  scrubbed  with  soap,  shaved,  and  disinfected.  If  the 
outflow  of  blood  is  not  free  it  can  be  made  to  become  so  by  muscular  con- 
tractions— for  instance,  by  opening  and  closing  the  hand.  When  a  sufficient 
amount  of  blood  has  escaped,  the  wound  is  closed  by  the  finger,  the  tourni- 
quet removed,  and  the  small  wound  covered  with  an  antiseptic  dressing, 
which  exerts  a  slight  pressure.  This  small  operation  must,  of  course,  be  car- 
ried out  with  a  careful  observance  of  antiseptic  precautions.  In  the  preanti- 
septic  days  suppurative  venous  thrombosis  and  death  from  pyaemia  were  of 
relatively  frequent  occurrence. 


Fig.  353. — Venesection  (right  elbow). 


Spontaneous  healing  of  a  Punctured  Wound  in  a  Vessel. — A  jDuucture 
in  an  artery  can  heal  spontaneously  if  there  is  not  too  much  gaping  of 
the  wound.  The  small  opening  is  closed  by  the  contraction  of  the 
elastic  walls  of  the  vessel  or  by  a  blood-clot.  In  the  case  of  larger 
arteries  the  formation  of  a  blood-clot  closing  the  hole  is  rendered  diffi- 
cult in  consequence  of  the  high  intra-arterial  pressure.  In  smaller 
arteries,  where  the  pressure  is  not  too  great,  the  coagulum  is  more 


§87.]  WOUXDS   OF   SOFT  PARTS.  473 

likely  to  remain  in  position,  and  the  clot  extending  into  the  lumen  of 
the  vessel  may  receive  fresh  layers  from  the  blood  flowing  by  it,  and 
thus  there  can  result  a  complete  closure  of  this  portion  of  the  vessel 
— in  other  words,  a  completely  occluding  arterial  thrombus.  But  in 
all  cases  where  spontaneous  healing  of  a  puncture  in  a  vessel  is  accom- 
plished by  a  clot,  there  is  the  danger  that  the  latter  may  be  swept 
away  at  any  time  should  there  be  considerable  intra-arterial  pres- 
sure, and  thus  a  renewal  of  the  bleeding  will  take  place — a  so-called 
secondary  hsemorrhage.  Punctured  wounds  of  veins  heal  spontane- 
ously very  readily  by  becoming  closed  with  a  thrombus.  The  blood 
coagulates  easily  here  on  account  of  the  slight  intravenous  pressure, 
and  the  walls  of  the  veins  collapse  if  not  prevented  from  doing  so  by 
natural  adhesions  to  the  surrounding  parts,  such  as  fascia  or  bones. 
After  veins  have  been  wounded  there  result  extensive  venous  thrombi, 
which,  especially  in  the  preantiseptic  days  of  sui'gery,  used  to  be  greatly 
dreaded,  as  they  often  underwent  suppuration  with  subsequent  general 
septic  poisoning  (pysemia). 

Punctured  Injuries  of  Nerves. — Punctured  injuries  of  nerves  may 
either  completely  or,  more  often,  partially  divide  them,  and  are  of 
special  practical  import.  The  extent  of  the  paralysis  caused  by  the 
injury  to  the  nerve  depends  upon  the  number  of  the  nerve  fibres 
which  have  been  divided.  If  the  nerve  is  not  cut  entirely  through^ 
spontaneous  healing  usually  follows  without  surgical  interference,  in 
case  the  nerve  was  at  the  same  time  not  too  much  contused.  In 
one  instance  I  saw  an  incurable  paralysis  of  the  ulnar  nerve  follow  a 
punctured  wound  of  the  nerve  made  by  a  steel  pen  filled  with  ink. 
The  nerve  was  months  afterwards  coloured  black  throughout  a  large 
part  of  its  extent.  Small  foreign  bodies,  such  as  needle  ]3oints,  bits  of 
glass,  etc.,  may  become  encapsulated,  and  they  often  give  rise  in  sen- 
sory or  in  mixed  nerves  to  very  painful  cicatrices  and  cicatricial  tu- 
mours (neuromata)  or  to  epileptiform  attacks.  Before  the  attack 
begins  the  patient  usually  feels  a  pain  in  the  cicatrix. 

Punctured  Wounds  of  Joints  and  of  the  Large  Cavities  of  the 
Body. — During  the  first  few  hours  or  days  after  the  injury  there 
may  often  be  doubt  as  to  whether  a  joint  or  a  large  cavity  of  the 
body,  with  one  of  its  vitally  important  organs,  has  been  injured.  It 
is  true  that  punctured  wounds  entering  joints  or  cavities  of  the 
body  not  infrequently  heal  up  without  treatment ;  but  in  other  cases 
it  becomes  evident,  after  the  lapse  of  a  few  days,  that  the  punctured 
wound  has  given  rise  to  suppuration  in  the  joint,  or  that  some  im- 
portant internal  organ  has  perhaps  received  such  injuries  as  to  cause 
death. 


474    INJURIES  AND  SURGICAL   DISEASES   OF   TUE  SOFT   PARTS. 

Traumatic  Emphysema. — In  conclusion,  mention  should  be  made  of 
the  occurrence  of  air  in  the  neighbourhood  of  punctured  wounds — 
traumatic  emphysema,  as  it  is  called.  If,  after  punctured  wounds,  air 
collects  to  a  greater  or  less  extent  in  and  under  the  skin,  there  will  be 
felt  a  slight  crepitation  in  the  affected  areas.  The  air  can  be  easily 
removed  by  pressing  and  kneading  with  the  fingers.  Traumatic  em- 
physema, or  the  collection  of  air,  especially  in  the  subcutaneous  cellu- 
lar tissue,  may  be  due  to  an  injury  to  an  organ  which  contains  air,  such 
as  the  lung  or  trachea.  After  injuries  of  the  lung  the  air  may  spread 
beneath  the  skin  over  the  entire  body  wherever  it  meets  with  the  least 
resistance.  Air  can  also  be  sucked  into  the  wound  from  without  by 
aspiration.  It  is  well  known  that  there  also  occasionally  arises  a  so- 
called  "spontaneous"  or  primary  emphysema  after  subcutaneous  ex- 
travasations of  blood,  especially  in  fractures  (Velpeau).  According  to 
H.  Fischer,  this  is  due  to  gases  from  the  blood  which  are  set  free  by 
the  action  of  an  acid,  such  as  the  lactic  acid  which  is  present  in  the 
contused  tissues.  This  so-called  spontaneous  emphysema  can  be  pro- 
duced experimentally  in  animals  by  exciting  in  them  an  extensive 
extravasation  of  blood,  and  then  injecting  lactic  acid  into  the  latter. 
In  one  case  which  Fischer  observed  the  gas  consisted  almost  entirely 
of  carbonic  acid.  A  careful  distinction  must  be  made  between  the 
various  kinds  of  emphysema  hitherto  described  and  the  emphysema  of 
decomposition — that  is,  the  collection  of  the  gases  of  decomposition  in 
the  rapidly  spreading  putrefactive  processes  which  may  take  place  in 
severe  open  wounds  as  a  concomitant  symptom  of  very  advanced  sepsis, 
and  in  the  so-called  malignant  oedema,  etc.  (pages  339-341). 

Further  Course  of  Punctured  Wounds. — The  further  course  of  punc- 
tured wounds  can  be  inferred  from  what  has  already  been  said ;  it  de- 
pends essentially  upon  whether  important,  deeply  situated  organs  such 
as  arteries,  nerves,  joints,  the  thoracic,  pei'itoneal  or  cranial  cavities, 
with  their  organs,  are  injured  or  not,  and  whether  excitants  of  inflam- 
mation in  the  form  of  bacteria  are  introduced  into  the  wound  by  the 
instrument  inflicting  the  injury,  and,  finally,  whether  a  foreign  body, 
Buch  as  the  point  of  an  instrument,  is  left  sticking  in  the  depths  of  the 
wound.  If  all  the  complications  which  have  been  mentioned  are 
absent,  then  punctured  wounds  heal  very  rapidly  like  simple  wounds. 
If  substances  which  excite  inflammation  or  bacteria  have  been  carried 
into  the  wound  by  the  instrument,  or  if  a  foreign  body  has  been  left 
in  the  wound  and  the  wound  has  not  received  antiseptic  treatment, 
suppuration,  abscesses,  or  a  deep  and  spreading  cellulitis  may  follow, 
and  possibly  death  from  pyaemia  and  sepsis.  After  a  simple  needle- 
prick  of  the  finger  septic  cellulitis  has  been  repeatedly  observed  which 


§87.]  WOUNDS   OF   SOFT   PARTS.  475 

ran  a  fatal  course,  and  with  such  rapidity  that,  although  a  disarticulation 
of  the  humerus  was  performed  on  the  fifth  or  sixth  day,  it  was  impos- 
sible to  save  the  life  of  the  patient.  I^ot  infrequently  punctured 
injuries  heal  superficially  without  suppuration,  and  yet  in  their  depths 
inflammation  and  suppuration  take  place,  especially  if  a  non-aseptic 
body  be  present. 

Behaviour  of  Foreign  Bodies  in  a  Wound. — Among  the  foreign  bodies 
which  may  be  left  behind  in  a  punctured  wound  are  broken-off  needle 
points  or  entire  needles,  knife  points,  sword  points,  splinters  of  glass  or 
wood,  etc.  Knife  and  sword  points  are  particularly  ai)t  to  break  off  after 
penetrating  bones.  Not  infrequently  the  foreign  bodies  remaining  in  the 
wound  heal  in  without  reaction  when  they  were  more  or  less  aseptic,  i.  e., 
clean.  Needles  have  been  found  embedded  in  the  brain  and  heart  (see 
Regional  Surgery).  E.  Simon,  while  conducting  an  autopsy  upon  an  adult, 
found  a  pin  healed  up  in  the  brain  which  had  probably  been  introduced 
through  the  open  fontanelle  during  the  first  year  of  his  life.  Huppert, 
while  making  the  post-mortem  examination  upon  an  idiot,  found  a  needle  in 
the  heart  which  extended  free  into  the  left  ventricle  five  to  six  lines.  The 
needle  was  enclosed  by  a  membrane  covered  with  endothelium,  and  had 
caused  no  particular  symptoms  during  life.  It  had  been  in  the  heart 
about  five  years.  Foreign  bodies  frequently  leave  their  original  location ; 
they  wander — i.  e.,  they  are  pushed  on  by  muscular  contraction  and  by  the 
elasticity  of  the  tissues.  They  may  get  into  internal  organs  and  cause  seri- 
ous trouble,  or  after  weeks,  months,  or  years  they  may  reach  the  skin  at  some 
point,  not  infrequently  causing  an  abscess,  from  which  they  are  then  ex- 
tracted. Billroth  removed  a  knitting-needle  almost  a  foot  long  from  the 
inguinal  region  of  a  thirty-year-old  idiot,  whither  it  had  probably  come  from 
the  vagina  or  rectum.  Needles  which  have  been  swallowed  also  pass,  with- 
out causing  trouble,  through  the  walls  of  the  stomach  and  intestine  and  may 
get  into  the  urinary  bladder,  where  they  give  rise  to  a  vesical  calculus  by 
deposition  of  urates  upon  the  needle.  In  another  case,  a  pin  which  had  been 
swallowed  lodged  in  the  oesophagus  and  killed  the  patient  by  puncturing  the 
aorta.  There  are  a  great  number  of  recorded  cases  illustrating  the  healing 
in  and  wandering  about  of  foreign  bodies,  and  I  could  add  to  the  list  a  con- 
siderable number  of  surprising  ones.  For  demonstrating  the  presence  of 
foreign  bodies  the  Roentgen  rays  may  be  employed  (see  Surgery  of  the  Bones, 
Gun-shot  Injuries,  §  124). 

The  healing  in  of  foreign  bodies  is  also  discussed  in  §  61. 

II.  Contused  Wounds. — The  contused  wounds  belong  to  the  com- 
plicated wounds  ;  the  tissues  are  crushed  by  the  force  applied  by  a 
blunt  object.  Is'ot  infrequently  they  are  a  part  of  very  extensive  in- 
juries in  which  the  soft  parts  and  bones  have  been  reduced  to  a  pulp. 
All  the  various  kinds  of  wounds  produced  by  blunt  instruments  belong 
to  the  class  of  contused  wounds ;  such,  for  instance,  are  the  wounds 
produced  by  "run-over"  accidents,  by  the  kick  of  a  horse,  etc.,  also 
the  numerous  machinery  and   railroad   injuries   so   very  common  in 


476    INJURIES   AND  SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 

modern  industries  and  transportation.  Gunshot  wounds  are,  in  the 
main,  contused  and  lacerated  wounds,  and  will  be  discussed  more  fully 
under  Gunshot  Fractures  (§  124).  Wounds  caused  by  bites  likewise 
belong  to  contused  wounds.  Bites  of  rabid  animals  and  poisonous 
snakes  are  described  in  §§  80  and  81. 

Appearance  of  Contused  Wounds. — The  appearance  of  contused 
wounds  differs  very  essentially  from  that  of  incised  wounds.  The 
borders  of  the  wound  are  not  smooth  and  of  normal  appearance,  but,  as 
a  result  of  the  bruising,  are  infiltrated  with  blood,  bluish-black  in  col- 
our, swollen,  and  often  irregular  in  shape.  The  bloody  infiltration  of 
the  tissues  varies  with  the  amount  of  force  to  which  they  have  been  sub- 
jected ;  not  infrequently  the  extravasated  blood  spreads  to  a  great  dis- 
tance in  the  parts  around  the  wound.  Occasionally  the  borders  of  the 
wound,  or  the  more  deeply  lying  parts,  are  so  crushed  that  they  sub- 
sequently perish.  AVhen  scratched  with  a  knife  no  blood  flows  out,  and 
the  patient  has  lost  all  sensation  in  the  affected  part.  The  appearance 
of  skin  which  has  been  badly  crushed  varies  according  to  the  amount  of 
blood  it  contains :  it  may  be  red  shading  off  into  bluish  or  dark  blue, 
violet,  or  white,  and  corpse-like  and  cold  to  the  touch.  Occasionally 
completely  crushed  skin  looks  apparently  normal  and  yet  it  is  dead. 
Not  infrequently  the  gangrene  of  the  skin  does  not  become  evident 
till  several  days  after  the  injury.  In  severe  cases  of  contused  wounds 
the  borders  of  the  wound  and  the  injured  tissues  in  general  are  torn 
into  shreds,  the  skin  is  more  or  less  extensively  stripped  from  the  un- 
derlying parts,  the  fascia,  tendons,  nerves,  and  vessels  are  mangled  ;  in 
short,  the  soft  parts  are  crushed  to  a  pulp  and  the  bones  broken  into 
numerous  fragments,  etc.  But  in  such  bad  cases  of  contused  wounds 
the  integrity  of  the  tissues  is  disturbed  not  only  at  the  point  of  the  in- 
jury, but  also  at  some  distance  from  it,  in  consequence  of  disturbances 
in  nutrition  due  to  the  infiltration  of  blood.  These  changes  in  the 
neighbourhood  of  the  wound  are  not  perceptible  to  the  eye  of  a  layman, 
but  are  recognised  by  the  surgeon,  and  on  account  of  this  bloody  infil- 
tration, if  there  is  any  necessity  for  an  amputation,  he  performs  it  at  a 
point  not  too  near  the  injury. 

Haemorrhage  in  Contused  Wounds. — When  large  arteries  and  veins 
are  injured,  such  as  the  femoral,  brachial,  or  axillary,  the  haemor- 
rhage, as  a  general  thing,  is  slight,  or  may  even  be  entirely  absent,  for 
the  reason  that  the  injured  vessels  are  crushed  with  the  other  parts, 
or  subjected  to  torsion,  in  the  same  way  as  described  in  §  28,  for 
checking  haemorrhage.  At  the  same  time,  after  such  severe  contu- 
sions there  is  a  high  grade  of  nervous  depression,  of  wound  stupor 
or   shock   (§  63).     As  a  result  of   this  shock  the  cardiac  activity  is 


§87.]  WOUNDS  OF   SOFT   PARTS.  477 

reflexlj  diminished  and  the  arteries  are  contracted,  and  hence  the  tend- 
ency to  haemorrhage  from  the  injured  and  contracted  arteries  is 
decreased.  During  the  next  few  days,  when  the  shock  passes  off  and 
the  action  of  the  heart  becomes  stronger,  secondary  haemorrhages  may 
readily  occur  from  the  crushed,  torn,  or  thrombosed  arteries,  and  may 
cause  the  death  of  the  patient  unless  prompt  aid  is  at  hand.  It  is  on 
account  of  these  dreaded  secondary  haemorrhages  after  contusions  that 
patients  with  such  injuries  should  be  carefully  watched.  The  haem- 
orrhages may  occur  on  the  first  to  second  day  with  the  abatement  of  the 
shock,  or  they  come  on  later,  on  the  fifth  to  the  tenth  day,  and  some- 
times later  stilh  The  later  secondary  haemorrhage  may  be  caused  by 
the  sloughing  away  of  the  contused  portion  of  the  wall  of  the  vessel 
which  has  become  necrotic,  or  by  suppuration  of  a  thrombus,  or  by 
erosion  of  the  artery,  as  a  result  of  suppuration  in  its  immediate  vicin- 
ity. But  the  primary  haemorrhage  in  contused  wounds  is  not  always 
slight ;  it  often  enough  happens  that  there  is  a  considerable  amount 
from  both  arteries  and  veins.  This  is  particularly  apt  to  be  the  case 
when  the  arteries  are  incompletely  torn,  so  that  the  injured  vessel  can- 
not retract  or  contract.  Under  these  conditions  haemorrhages  into  the 
surrounding  tissues  will  also  be  observed,  forming  so-called  traumatic 
aneurisms  similar  to  those  following  punctured  wounds  of  arteries. 

III.  Lacerated  Wounds. — Lacerated  wounds  present  essentially  the 
same  peculiarities  as  contused  wounds.  The  larger  lacerated  wounds 
have,  in  general,  a  mangled  appearance.  Tearing  away  of  entire  ex- 
tremities— the  upper  or  lower^  by  machinery,  for  instance — belong  to 
the  severest  class  of  injuries  which  a  surgeon  ever  sees.  In  such  cases 
the  injured  person  shows  all  the  symptoms  of  severe  shock,  in  conse- 
quence of  which  death  not  infrequently  follows.  Even  when  entire 
extremities  are  torn  away  there  may  be  no  haemorrhage  of  any  impor- 
tance, for  the  reasons  stated  above.  In  the  hospital  at  Zurich  an  arm, 
including  the  scapula  and  clavicle,  has  been  preserved,  which  was  torn 
away  without  causing  death  by  haemorrhage,  as  the  axillary  artery  was 
twisted  on  itself  as  in  torsion. 

Further  Course  of  Contused  and  Lacerated  Wounds. — The  further 
course  of  contused  and  lacerated  wounds  depends  upon  the  severity  of 
the  injury,  upon  the  introduction  of  micro-organisms  at  the  time  of 
the  injury  or  subsequently,  and  whether  the  wound  receives  antiseptic 
treatment  at  as  early  a  period  as  possible.  Even  very  badly  contused 
and  lacerated  wounds  may  heal  without  any  marked  secretion  or  sup- 
puration if  they  remain  covered  by  an  aseptic  blood-clot  beneath  an 
antiseptic  dressing.  The  time  which  contused  and  lacerated  wounds 
require  for  healing  is  longer  than  that  necessary  in  other  wounds.     In 


4Y8    INJURIES  AND  SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 

the  case  of  contusions  of  any  gravity,  the  wound  resulting  from  the 
injury  usually  "purities  itself"  from  the  superlicial,  mortiiied,  or  half- 
dead  tissues,  by  giving  off  a  discharge  or  secretion  which  is  at  first 
bloody,  then  serous,  and  finally  purulent.  When  the  wound  is  treated 
aseptically  the  discharge  has  no  odour,  but  if  putrefactive  changes  take 
place  it  is  discoloured,  dirty,  and  often  has  a  characteristic  smell.  The 
mortified  (gangrenous)  and  half -dead  tissues  are  cast  off  by  suppuration 
— that  is,  at  the  boundary  line  between  the  healthy  and  dead  parts,  at 
the  so-called  line  of  demarcation,  there  ensues  a  vigorous  proliferation 
of  the  tissue  cells  and  a  collection  of  wandering  cells.  Subsequently 
a  cellular  and  vascular  granulation  tissue  forms,  from  the  surface  of 
which  pus  is  given  off  in  large  quantities.  By  this  demarcating  sup- 
puratioTi  the  dead  parts  are  separated  from  the  living.  The  casting  off 
of  the  dead  tissue  goes  on  with  different  degrees  of  rapidity,  depending 
particularly  upon  the  vascularity  of  the  injured  tissue.  Hence  it  fol- 
lows that  in  the  case  of  dead  portions  of  tendons,  fascia,  and  bone,  the 
process  takes  a  particularly  long  time.  Still  there  are  great  individual 
differences  in  this  respect. 

Contused  and  lacerated  wounds  offer,  in  general,  a  favourable  me- 
dium for  bacteria,  especially  the  former.  The  micro-organisms  usually 
enter  the  wound  at  the  moment  of  the  injury — for  example,  when  upon 
a  dirty  street  a  wagon-wheel  passes  over  an  extremity ;  or  the  instru- 
ment which  inflicts  the  injury,  the  dirty  clothes,  or  the  skin  of  the  pa- 
tient, are  the  means  by  which  the  bacteria  are  carried  into  the  wound. 
As  a  result  of  the  presence  and  development  of  the  bacteria  in  the 
wound,  the  various  infectious-wound  diseases  can  originate.  These 
have  been  described  in  §  66  et  seq.  After  extensive  contused  wounds, 
those  spreading,  septic  forms  of  cellulitis,  which  we  have  studied  in 
§  YO,  are  particularly  apt  to  occur.  If  a  contused  wound  has  cast  off 
its  mortified  layer,  and  has  passed  into  the  stage  of  granulation,  the 
healing  is  ordinarily  assured  if  no  transgression  is  made  of  the  rules  of 
antisepsis. 

The  more  minute  anatomical  changes  which  take  place  in  the  heal- 
ing of  a  wound,  in  the  formation  of  the  scar,  and  the  cicatricial  con- 
tractures, etc.,  have  been  described  in  §  61. 

As  regards  the  course  of  injuries  of  particular  regions  of  the  body, 
I  must  refer  the  reader  to  my  Text-Book  on  Regional  Surgery. 

§  88.  The  Treatment  of  Wounds  of  Soft  Parts. — The  treatment  of 
every  fresh  wound  of  the  soft  parts  is  conducted  upon  antiseptic 
principles,  in  the  manner  described  in  §  6,  §  20,  and  §§  44-49.  The 
treatment  begins  with  a  careful  examination  of  the  wound,  to  deter- 
mine whether  large  vessels,  tendons,  or  nerves  have  been  injured,  or 


§88.]  THE   TREATMENT   OP  WOUNDS   OF  SOFT   PARTS.  4Y9 

whether  a  joint  or  cavity  of  the  body  has  been  opened.  Our  first  care 
should  be  the  arrest  of  the  haemorrhage,  as  we  have  described  in 
§§  27-30.  The  following  brief  description  of  hasmostasis  will  suffice : 
On  the  extremities  it  can  be  best  carried  out  with  the  assistance  of 
Esmarch's  artificial  ischsemia.  The  wound,  particularly  if  a  punctured 
wound,  must  always  be  enlarged  sufficiently  to  lay  bare  the  point  where 
the  vessel  has  been  injured,  and  to  permit  of  its  inspection.  Every 
large  artery  in  the  wound  which  has  been  punctured  or  cut  must  re- 
ceive a  double  ligature — that  is,  the  vessel  must  be  tied  on  the  central 
and  peripheral  side  of  the  injured  point,  as  only  in  this  way  can  sec- 
ondary haemorrhage  be  prevented  from  the  peripheral  end  of  the  ves- 
sel, or  from  the  puncture  in  the  artery  (Rose).  If  only  the  central 
end  of  the  artery  is  ligated,  a  secondary  haemorrhage  could  occur  from 
the  unligated  peripheral  end  of  the  vessel,  or  the  puncture  in  its  wall, 
very  soon  after  the  establishment  of  the  collateral  circulation.  But 
the  central  and  peripheral  ligation  of  the  artery  in  punctured  wounds, 
for  example,  is  not  sufficient.  All  the  branches  given  off  from  the 
vessel  in  the  neighbourhood  of  the  injury  must  also  be  secured  at  the 
same  time,  if  one  wishes  to  be  perfectly  sure  of  preventing  haemor- 
rhage from  the  puncture  in  the  artery  (Rose).  After  ligating  the 
main  vessel  and  the  branches,  the  injured  portion  of  the  vessel  can_ 
then  be  extirpated,  though  it  is  not  necessary.  Injuries  of  large  veins 
are  treated  in  essentially  the  same  manner  as  those  of  arteries.  As 
regards  the  special  technique  for  ligating  arteries  and  veins,  I  must 
refer  the  reader  to  §  30. 

Temporary  Hsemostasis. — Often  enough  the  physician,  especially  in 
the  country,  is  not  so  situated  as  to  be  able  to  immediately  and  perma- 
nently arrest  the  haemorrhage,  but  must  be  content  with  provisional 
haemostasis  carried  out  by  some  sort  of  dressing  in  order  to  transport 
the  j)atient  to  a  hospital.  The  simplest  means  of  arresting  haemorrhage 
temporarily  consist,  as  already  mentioned  in  §  29,  in  applying  pressure 
upon  the  bleeding  point  by  the  finger,  a  dressing,  or  an  elastic  band- 
age, and  in  applying  pressure  upon  the  afferent  artery  by  the  finger,  by 
tourniquets,  an  elastic  bandage,  Esmarch's  elastic  tourniquet  (§  19)^ 
and  finally  by  forced  flexion — for  example,  of  the  elbow  joint  or  the 
knee  if  the  haemorrhage  takes  place  in  a  region  supplied  by  the 
branches  of  the  brachial  or  popliteal  arteries. 

Further  Treatment  of  Wounds  of  Soft  Parts. — When  the  bleeding 
has  received  the  most  careful  attention,  it  is  advisable  to  examine  the 
wound  thoroughly  with  antiseptic  precautions  to  determine  whether 
and  to  what  extent  deeply  placed  parts,  such  as  tendons,  muscles, 
nerves,  or  bones,  have  been  injured,  and  whether  the  wound  is  ren- 


480     INJURIES  AND  SURGICAL   DISEASES   OF   THE   SOFT   PARTS. 


derecl  unclean  bv  the  presence  of  a  foreign  body.  The  examination 
should  be  performed  as  gently  as  possible,  and  an  especial  warning 
should  be  given  against  the  too  rough  use  of  the  pi-obe.  By  means  of 
the  latter  it  is  easily  possible  to  penetrate  a  thin,  undivided  layer  of 
tissue  over  a  joint,  over  the  peritonaeum,  the  pleura,  etc.,  and  thus 
change  a  relatively  simple  wound  into  a  complicated  one.  We  shall 
go  into  the  treatment  of  penetrating  wounds  of  joints  or  of  the  cavi- 
ties of  the  body  in  another  chapter  (§  123,  AYounds  of  Joints).  If  it  is 
found  that  muscles,  tendons,  or  nerves  have  been  divided,  they  must 
be  reunited  by  sutures. 

Tenorrhaphy— Tendon  Suture. — The  best  method  of  performing 
tenorrhaphy  is  Wolfler's.  He  passes  the  suture  through  the  tendon 
stumps  transversely,  about  one  centimetre  from  their  free  ends,  either 
once  or  repeatedly,  and  then  ties  the  ends  of  the  sutures  together. 

The  two  ends  of  the  tendon 
can  then  be  sutured  to  the 
surrounding  tissue  by  means 
of  a  number  of  interrupted 
stitches  or  a  continuous  su- 
ture. Trnka  recommends 
the  use  of  lateral  loops  (Fig. 
354)  for  holding  the  su- 
tured ends  in  better  contact. 
Witzel  recommends  the  ap- 
plication of  a  "  retention 
ligature"  passed  transverse- 
ly through  each  stump  of  the  tendon  about  one  centimetre  from  its  cut 
end ;  by  means  of  these  retention  ligatui-es  the  tendon  ends  are  drawn 
together  and  then  united  by  catgut  sutures.  Finally,  the  two  retention 
ligatures  are  knotted  together,  and,  if  desired,  the  tendon  sheath  is 
sutured.  Then  follow  drainage  and  closure  of  the  cutaneous  wound. 
It  is  sometimes  difficult  to  iind  the  central  end  of  the  tendon,  which 
retracts  to  a  greater  or  less  extent,  in  consequence  of  the  contraction  of 
the  muscle  attached  to  it,  and  not  infrequently  the  tendon  sheath  has 
to  be  opened  for  a  long  distance  upwards — best  on  its  lateral  aspect — 
to  find  the  central  end.  The  longitudinal  incision  made  through  the 
skin  for  searching  for  the  tendon  stump  should  always  be  placed  not 
over  the  tendon  but  to  one  side  of  it ;  this  is  the  best  way  to  avoid  a 
subsequent  adhesion  of  the  tendon  to  the  skin.  To  facilitate  the  find- 
ing of  the  central  end  of  the  tendon,  it  is  also  a  good  plan  to  explore 
its  sheath  with  a  sharp  hook,  with  which  the  tendon  may  be  seized  and 
drawn  out,  or  the  extremity  may  be  enveloped  by  an  elastic  bandage 


Fig.  354. — Tenorrhaphy  after  Trnka  :  a,  insertion  of  the 
suture ;  b,  suture  tied  at  /'  and  the  two  loops  tied 
together  at  e;  c,  forinatiou  of  loops  at  g  by  means 
of  two  sutures,  the  latter  are  tied  at  ft. 


§  88.]  THE   TREATMENT   OF  WOUNDS   OF   SOFT   PARTS.  481 

applied  from  the  centre  towards  the  periphery — the  reverse  of  the  usual 
manner  of  application.  The  muscle  to  which  the  tendon  belongs  mav 
also  be  rubbed  or  pushed  do^m  from  the  outside.  Yery  great  difficulty 
sometimes  attends  the  discovery  of  the  central  tendon  stump  in  old 
cases  of  tendon  division.  The  retraction  of  the  central  end,  under 
these  circumstances,  is  occasionally  very  considerable,  and  the  above- 
mentioned  methods  for  discovering  the  central  stump  of  the  tendon 
are  not  successful,  because  the  stump  is  adherent  to  the  tendon  sheath. 
Madelung  has  advised,  in  such  cases,  that  the  central  end  of  the  tendon 
be  sought  for  by  an  incision  located  on  the  central  side  of  the  wound, 
or  rather  of  the  cicatrix,  and  that  the  tendon  be  freed  and  pushed 
towards  the  periphery  with  a  probe,  or,  perhaps  better,  with  a  long, 
half-curved  needle.  For  the  same  reasons  mentioned  before,  it  is  bet- 
ter to  make  the  longitudinal  incision  to  one  side  of  the  tendon  sheath. 
If  the  approximation  of  the  two  tendon  stumps  presents  difficulties  on 
account  of  the  tension  being  too  great,  as  may  be  the  case  when  there 
has  been  a  loss  of  substance,  it  is  advisable  to  cut  a  flap  with  a  pedicle 
from  one  or  each  of  the  tendon  stumps.  The  ends  of  the  tendon  are 
split  up  to  a  point  near  the  cut  surfaces,  and  the  pedunculated  flaps  thus 
formed  which  are  still  attached  to  the  tendon  are  turned  down  into  the 
defect  and  united  with  catgut  sutures.  Portions  of  tendons  taken  from 
young  dogs  or  rabbits  have  been  successfully  engrafted  in  tendon 
defects,  and  attempts  have  been  made  to  repair  losses  of  substance  by 
interposing  strands  of  catgut  (Gluck,  Monod).  The  strands  of  catgut 
are  absorbed,  and  in  their  place  tendon  tissue  is  formed.  The  catgut 
or  silk  acts  as  a  framework  along  which  the  newly  formed  connective 
tissue  or  tendon  tissue  grows.  But  even  in  cases  where  the  tendon 
ends  could  not  be  united  but  only  drawn  near  one  another,  satisfactory 
results  have  been  observed  as  regards  the  function  of  the  muscle 
involved.  In  such  cases,  fibrous  bands  form  between  the  tendon 
stumps,  as  in  tenotomy,  or  the  stumps  sometimes  become  adhei-ent  to 
the  skin,  and  the  skin  finally  becomes  so  movable  and  extensible  that 
it  follows  the  movements,  or  rather  traction,  of  the  tendon.  Duplay 
and  Tillaux  obtained  a  good  result  by  suturing  the  peripheral  end  of 
the  divided  tendon  of  the  extensor  longus  pollicis  muscle  (the  cut  ends 
were  six  centimetres  apart,  and  hence  could  not  be  united)  into  a  slit 
made  in  the  underlying  tendon  of  the  extensor  carpi  radialis  longior. 
Hager  and  others  have  likewise  successfully  united  the  peripheral  ten- 
don stump  with,  the  tendon  of  a  neighbouring  muscle  having  a  similar 
action,  when  direct  tenorrhaphy  could  not  be  carried  out  on  account  of 
too  great  a  distance  between  the  tendon  stumps.  By  means  of  trans- 
plantation of  tendons  it  is  possible  to  improve  or  even  cure  paralysis. 
34 


4S2    INJURIES  AND  SURGICAL  DISEASES   OF   THE   SOFT   PARTS. 


This  is  done  by  suturing  paralysed  muscles  or  tendons  to  unparalysed 
ones.  This  can  be  done  in  various  ways.  The  tendon  of  the  j)aralysed 
muscle  may,  for  example,  be  divided,  and  the  distal  end  of  the  same- 
is  united  to  a  non-paralysed  muscle  or  tendon,  or  to  the  central  end  of 
a  divided  non-paralysed  tendon.  Tlie  tendons  may  also  be  divided 
longitudinally  or  pedunculated  flaps  formed,  and  in  this  way  paralysed 
and  non-paralysed  muscles  united  by  suture.  A  number  of  surgeons 
have  obtained  good  results  from  this  transplantation  method  in  para- 
lytic conditions  of  the  leg,  foot,  etc. — e.  g.,  in  paralytic  pes  varus,  pes 
calcaneus,  and  pes  valgus  (see  Text-Book  of  Eegional  Surgery). 

Tenoplasty  for  Lengthening  a  Retracted  (Shortened  Tendon). — II. 
Sporon  has  devised  the  following  means  of  lengthening  a  tendon  whicli 
has  become  shortened  by  the  repair  of  an  injury  of 
the  tendon  or  from  some  other  cause  :  After  exposing 
the  tendon  by  a  longitudinal  incision  some  five  centi- 
metres in  length,  two  parallel  longi- 
tudinal incisions  of  equal  length  are 
made  in  the  long  axis  of  the  tendon, 
one  placed  one  centimetre  higher  than 
the  other.  From  the  upper  end  of  the 
higher  incision  and  the  lower  end  of 
the  second,  transverse  incisions  are 
made  in  opposite  directions  (Fig.  357). 
Thus  the  tendon,  without  being  di- 
vided, can  be  lengthened  an  amount 
equal  to  the  combined  lengths  of  the 
two  longitudinal  incisions.  Lange 
(iSTew  York)  recommends  division  of 
the  tendon  within  the  muscle,  for  the 
purpose  of  lengthening  tendons.'  This  is  done  with  or  without  teno- 
plasty (Fig.  355),  and  consists  in  dividing  the  tendon  within  the  inuscle. 
with  preservation  of  the  muscle  fibres  on  the  sides. 

Suture  of  Muscles. — Transversely  divided  muscles  are  united  by  in- 
terrupted catgut  sutures.  In  cases  of  loss  of  muscular  substance — as 
when  a  piece  is  torn  out  of  the  continuity  of  the  muscle — pedunculated 
flaps  can  be  turned  down  into  the  defect  and  united  by  sutures,  as  ia 
cases  of  defects  in  tendons. 

Transplantation  of  Muscular  Substance  in  Cases  of  Muscular  Defects. — 
In  cases  of  loss  of  substance  in  muscles,  Gluck,  Ilelferich,  and  others 
have  proposed  the  implantation  of  muscular  tissue  taken,  for  example, 
from  a  dog.  According  to  the  experiments  of  Magnus  and  Volkmann, 
a  piece  of  muscle  thus  implanted  always  perishes,  and  is  absorbed  in 


plasty  liv  the  for- 
niatioa  of  a  pe- 
dunculated nap 
from  one  end  of 
a  tendon. 


Fig 


—  Teno- 
plasty :  L.  pe- 
dunculated flap; 
J\',  suture. 


§88.] 


THE   TREATMENT   OF  WOUNDS   OF   SOFT   PARTS. 


483 


the  same  waj  as  an  implanted  portion  of  a  nerve  taken  from  an  animal. 
As  a  general  rule,  therefore,  one  abstains  from  the  transplantation  of 
a  portion  of  muscle  in  case  of  loss  of  muscular  sub- 
stance ;  it  is  unnecessary  in  small  muscular  defects, 
and  even  when  the  loss  of  substance  is  large  the  stunip 
of  the  muscle  can  become  connected  by  cicatricial 
tissue — a  cicatricial  inscrijptio  tenclinea,  as  it  were — 
and  not  suffer  any  loss  of  function.  Fig.  358  shows 
very  well  that  really  extensive  muscular  defects  may 
be  so  completely  compensated  for  by  cicatricial  tissue, 
that  the  contraction  of  the  muscle  as  a  whole  is  not 
disturbed  by  the  interposed  cicatrix.  Gluck  has  also 
attempted  to  remedy  losses  of  muscular  substance  by 
the  interposition  of  strands  of  catgut,  as  in  defects  in 
nerves  and  tendons.  F,^.  S57.-Leugth- 

enincf   of  a  ten- 

Regeneration  of  Muscle.— It  is  well  known  that  con-         don  (Sporon). 
tractile  muscular  substance  has  but   slight  capabilities  of 
regeneration.     Muscular  defects  are  always  filled  up  by  connective  tissue,  by 
cicatricial  tissue,  and  not  by  new-formed  contractile  muscular  fibi'es.    But  in 

the  neighbourhood  of  the  cicatrix,  and  in  slight 
injuries  and  contusions  of  muscles,  regenerative 
changes  are  observed  which  have  been  carefully 
studied  by  Weber,  AValdeyer,  Kraske,  and  others. 
At  first  an  enlargement  and  proliferation  of  the 
nuclei  of  the  muscle  fibres  takes  place,  and  large, 
mononuclear  and  polynuclear  cells  appear,  which 
take  the  place  of  the  muscle  fibres  which  have 
disappeared  and  fill  up  the  muscular  intei'stices. 
These  prolifei'ated  nuclei  of  the  old  muscle  fibres 
are  the  formative  cells  of  the  new  fibres  ;  they 
arrange  themselves  into  spindle-shaped  cells  lying 
side  by  side,  in  which  very  soon  a  fine  longitudi- 
nal fibrillated  striation  is  recognisable,  and  by  the 
end  of  the  third  week  the  first  traces  of  transverse 
striation  make  their  appearance.  Nauwerck,  con- 
trary to  these  teachings,  which  have  been  pretty 
generally  accepted,  was  never  able  to  prove  that 
the  proliferated  new-formed  muscular  corpuscles 
changed  into  muscular  fibres.  According  to  Nau- 
werck, the  new  formation  of  muscular  tissue  takes 
place  in  the  manner  that  E.  Neumann  described ; 
it  proceeds  from  the  old  muscular  fibres  by  ter- 
minal and  lateral  budding,  and  by  longitudinal 
cleavage  and  segmentation  of  the  old  and  newly 
formed  muscular  fibres.  The  new-formed  muscular  fibres  penetrate  the  cica- 
trix to  a  greater  or  less  extent.     The  freer  the  process  of  repair  is  from  reac- 


FiG.  35b — Paitidl  Liicular  loss 
of  sub.stance  in  the  muscles  of 
the  upper  arm  of  a  twenty- 
two-year-old  factory  girl,  i-e- 
sulting  from  a  gang-renous 
abscess  which  was  caused  in 
her  fifth  year  hy  the  bite  of 
an  insect :  no  disturbance  of 
motion  (Uhde). 


4S4    INJrRIES  AND  SURGICAL   DISEASES  OF   THE   SOFT    PARTS. 

tion  the  more  complete  is  the  regeuex'ation.  Transplanted  portions  of  muscle, 
as  we  have  said,  never  retain  their  vitality ;  they  perish  without  exception, 
and  are  suhsequently  absorbed.  In  their  place  a  connective-tissue  cicatrix 
forms,  which  possesses  to  a  certain  extent  the  function  of  muscle,  like  every 
other  cicati'ix  in  muscle. 

Regeneration  of  Tendon  Tissue.— The  regeneration  of  tendon  tissue  after 
division  of  u  tendon  j)roceeds  partly  from  the  tendon  sheath  and  partly  from 
the  stump  of  the  tendon.  After  the  lapse  of  two  to  three  days  vigorous  pro- 
liferative changes  and  numerous  caryocinetic  figures  are  observed  in  the  cells 
of  the  tendon  sheath.  The  cells  in  the  stumps  of  the  tendon,  which  degenerate 
in  part  in  the  neighbourhood  of  the  wound,  likewise  on  the  fourth  to  fifth 
day  take  a  share  in  the  healing  process  (Viering).  The  cells  of  the  tendon 
play  a  variable  part  in  the  formation  of  the  cicatrix ;  in  the  main,  however, 
the  latter  is  formed  by  the  cells  of  the  tendon  sheath  (Busse).  By  prolifer- 
ation of  the  cells  of  the  tendon  sheath  and  those  of  the  tendon  proper  there 
originates  a  granulation  tissue,  consisting  of  many-shaped  cells,  by  which  the 
tendon  stumps  are  united.  The  granulation  tissue  then  gradually  changes 
into  normal  tendon  tissue. 


Neurorrhaphy.  The  Union  of  Divided  Nerves  hy  Suture. — There 
are  two  nietliods  of  performing  nerve  suture  after  a  nerve  has  been 
divided,  for  instance,  in  an  extremity :  the  direct  nerve  suture  through 
the  substance  of  the  nerve  itself,  and  the  indirect  or  ijaraneurotic 
nerve  suture  through  the  connective  tissue  en- 
closing the  nerve  (Fig.  359).  Both  methods 
have  yielded  good  results,  especially  since  the 
introduction  of  antisepsis.  Aseptic  catgut  is 
the  most  desirable  suture  material  for  neuror- 
rhaphy. The  direct  nerve  suture  is  best  per- 
formed as  Woll)erg  has  recommended — by  pass- 
ing a  fine  needle,  flattened  laterally,  through 
the  ends  of  the  nerve  about  one  centimetre 
from  the  cut  surface,  keeping  the  suture  as  su- 
perficial as  possible  and  not  passing  it  through 
the  entire  thickness  of  the  nerve,  so  that  the 
nerve  fibres  are  damaged  as  little  as  possible.  Two  lateral  sutures  are 
more  sparing  of  the  nerve  and  hold  it  more  securely  than  one  suture 
through  the  middle  of  the  nerve  stump.  According  to  observations 
hitherto  made,  di/rect  nerve  suture  has  never  produced  any  bad  effects. 
The  imraneurotic  suture  passes,  as  we  have  said,  entirely  outside  of  the 
substance  of  the  nerve  itself;  one  suture  is  apphed  laterally  to  the 
nerve  through  the  paraneurotic  connective  tissue  (Fig.  359),  and  then, 
if  necessary,  one  is  placed  behind  and  another  in  front  of  the  nerve, 
and  thus  the  nerve  stumps  are  brought  indirectly  into  contact.  I  have 
found  that  a  combination  of  both  kinds  of  nerve  suture  is  vei-y  advan- 


FiG.  .359. — Nerve  suture  passed 
tbrouijli  paraneurotic  con- 
nective tissue. 


§88.]  THE   TREATMENT   OF   WOUNDS   OF   SOFT   PARTS.  4,85 

tageous,  particularly  in  cases  where  there  is  some  tension  after  the  in- 
troduction of  the  sutures.  The  nerves  are,  however,  so  extensible  and 
elastic  that  by  exerting  traction  upon  the  central  and  peripheral  stumps 
it  is  easy  to  avoid  any  tension. 

Secondary  Neurorrhaphy. — In  old  cases  of  divided  nerves,  "  sec- 
ondary neurorrhaphy"  should  always  be  performed.  The  operation 
has  yielded  very  satisfactory  results.  Simon  and  Esmarch  have  suc- 
cessfully performed  neurorrhaphy  ten  to  sixteen  months  after  the 
nerve  has  been  divided,  and  in  one  case  Jessop  improved  the  paralytic 
symptoms  by  suturing  the  ulnar  nerve  nine  years  after  the  injury.  In 
old  cases  of  nerve  division  the  stumps  of  the  nerve  are  sought  for, 
freed  from  the  connective-tissue  adhesions,  and  fresh  surfaces  made  at 
the  ends,  which  are  then  united  by  one  or  two  aseptic  catgut  sutures. 

Operative  Treatment  of  Loss  of  Nerve  Substance. — If  there  is  a  loss 
of  nerve  substance — a  nerve  defect — rendering  it  impossible  to  unite 
by  sutures  the  widely  separated  ends  of  the  nerve,  various  plans  can  be 
followed.  In  the  first  place,  an  attempt  can  be  made  to  stretch  the 
nerve  by  traction,  so  as  to  make  it  possible  to  unite  the  ends  by  sutures. 
If  this  cannot  be  done — i.  e.,  if  the  nerve  stumps  cannot  be  brought  suf- 
ficiently near  together — flaps  with  pedicles  may  be  formed  fi'om  one 
or  both  ends  of  the  nerve,  turned  down  into  the  defect  and  united 
by  catgut  sutures  iautojplasie  nerveuse  d  lamheaux  Letievanf).  I  prac- 
tised this  method  successfully  upon  the  median  and  ulnar  nerves  three 
months  after  the  injury,  and  the  paralysed  right  hand  of  the  patient 
became  so  useful  that  she  wrote  me  a  letter  of  thanks  a  year  after  the 
operation.  Dittel,  Brenner,  and  others  have  also  had  good  results  with 
this  method. 

Nerve-grafting. — Letievant  recommends  nerve-grafting  {greffe  ner- 
veuse) for  loss  of  substance  in  nerves.  The  peripheral  end  of  a  divided 
nerve  is  united  with  an  adjoining  nerve  by  freshening  the  latter  on 
one  side  and  fastening  the  peripheral  end  of  the  injured  nerve  in  the 
freshened  area  by  means  of  catgut ;  or  the  peripheral  end  of  the  nerve 
is  inserted  between  the  fibres  of  the  uninjured  nerve.  By  the  use  of 
the  Mtter  method  Despres  inserted  the  peripheral  end  of  the  median 
nerve  between  the  fibres  of  the  ulnar  nerve,  and  the  patient  recovered 
the  use  of  his  hand.  Sanger  cured  a  paralysis  of  the  musculo-spiral 
nerve  caused  by  a  traumatic  defect  by  suturing  the  peripheral  end  of 
this  nerve  to  the  median.  M.  Gunn  has  experimented  with  the  method 
npon  animals  with  successful  results. 

Lobker's  Procedure. — In  a  case  of  loss  of  substance  in  the  flexor  mus- 
cles of  the  forearm,  involving  the  median  and  ulnar  nerves,  Lobker 
exsected  a  portion  of  bone  subperiosteally  from  the  radius  and  ulna 


4SG    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT  PARTS. 

correspondinsj  to  the  size  of  the  defect,  and  then  united  by  sutures  the 
freshened  stiini])s  of  the  tendons  and  nerves. 

Transplantation  of  a  Portion  of  Nerve  into  a  Nerve  Defect. — The  trans- 
plantation of  a  piece  of  one  nerve  into  a  nerve  defect  in  another  was 
first  performed  by  Philippeaux  iind  Yulpian.  They  were  successful  in 
causing  a  portion  of  the  lingual  nerve  to  heal  into  the  hypoglossal. 
The  latter  completely  regained  its  function.  Recently  Gluck  has  re- 
peated these  experiments,  successfully  implanting  a  portion  of  the 
sciatic  nerve  three  centimetres  long,  taken  from  a  hen,  into  a  corre- 
sponding defect  in  the  sciatic  nerve  of  a  rabbit.  Eleven  days  after  the 
operation  the  sciatic  nerve  in  the  rabbit  is  said  to  have  become  capable 
of  conducting  mechanical  and  electrical  stimulation.  This  uncommonly 
rapid  restoration  of  conductivity  in  a  sutured  nerve,  and  particularly  in 
one  which  had  been  united  by  transplantation,  contradicts  all  the  obser- 
.vations  hitherto  made  on  this  subject.  In  spite  of  the  perfect  union  of 
the  transplanted  portion  of  nerve,  Johnson,  after  twenty-three  to 
twenty-four  days,  was  unable  to  obtain  a  contraction  of  the  muscles 
supplied  by  the  nerve  in  question  when  he  stimulated  the  latter  with 
the  induction  curi'ent  at  a  point  central  from  the  transplantation,  but 
he  did  cause  contractions  by  direct  stimulation  of  the  muscles.  At  all 
events,  so  rapid  a  restoration  of  nervous  conductivity  as  Gluck  de- 
scribes, after  the  transplantation  of  pieces  of  nerve  into  nerve  defects, 
can  probably  occur  in  only  the  most  exceptional  cases.  Perhaps  there  is 
in  these  cases  a  conduction  along  collateral  nerve  branches.  As  a  general 
thing,  the  nerve  fibres  contained  in  the  transplanted  piece  of  nerve  will 
perish ;  but  they  prevent  connective  tissue  from  growing  into  the  nerve 
defect,  and  thus  render  it  possible  for  the  nerve  fibrils  which  develop 
from  the  central  end  of  the  nerve  to  readily  find  their  way  to  the  pe- 
ripheral end.  Furthermore,  it  is  my  opinion  that  the  nerve  fibres  in 
the  above-described  pedunculated  nerve  fiaps  do  not  persist ;  but  the 
flaps  prevent  connective  tissue  from  growing  into  the  nerve  defect,  and 
in  this  way  merely  facilitate  the  bridging  over  of  the  nerve  defect  ^\^th 
newly  formed  nerve  fibres.  Yanlair  has  shown  that  losses  of  nerve 
substance — nerve  defects — can  be  repaired  by  inserting  the  end  of  the 
nerve  into  an  open  decalcified  bone  drain  or  bone  canal.  By  this  means 
the  ingrowth  of  connective  tissue  into  the  nerve  defect  is  prevented, 
and  the  bridging  over  of  the  defect  with  newly  formed  nerve  fibres  is 
facilitated  by  the  presence  of  the  open  canal.  Gluck  bridged  over  a 
defect  five  centimetres  in  length  in  the  musculo-spiral  nerve  by  means 
of  a  bundle  of  catgut;  a  year  afterwards  the  function  was  entirely 
restored. 

Corresponding  to  the  gradual  regeneration  which  takes  place  in  the 


§88.]  THE   TREATMENT   OF  WOUNDS  OF   SOFT  PARTS.  487 

injured  part  of  the  nerve  by  the  bridging  of  it  over  with  newly  formed 
nerve  fibres,  the  conductivity  of  a  nerve  after  it  has  been  sutured  only 
returns  after  the  lapse  of  some  time.  Within  some  two  to  four  weeks 
first  sensibility  returns  in  the  affected  skin  area,  and  then  motility, 
though  in  exceptional  cases  the  improvement  in  sensation  appears 
later  than  that  in  motion.  As  regeneration  advances  gradually  from 
the  centre  towards  the  periphery  the  functional  disturbances  disappear 
at  first  in  the  parts  that  are  nearest,  and  much  later  and  more  imper- 
fectly in  the  more  distant  parts,  or  those  parts  may  remain  permanently 
paralysed.  The  return  of  motility  is  the  only  means  of  determining 
whether  or  not  a  neurorrhaphy  has  been  successful  in  a  nerve  with 
motor  and  sensory  fibres,  inasmuch  as  sensation  may  become  restored 
by  means  of  the  collateral  branches  of  neighbouring  nerves.  From 
observations  hitherto  made,  sixteen  to  nineteen  days  can  be  considered 
as  the  earliest  period  at  which  return  of  motility  begins  after  a  nerve 
suture ;  in  other  cases  it  began  only  after  the  lapse  of  several  months, 
sometimes  ten  to  twelve.  But  ei'rors  of  observation  are  possible  as 
regards  improvement  in  motility  after  suturing  a  nerve,  because  here 
also,  as  we  saw,  the  muscles  which  are  not  paralysed  may  take  on  the 
functions  of  those  which  are,  and  more  or  less  compensate  for  the 
absence  of  activity  in  the  really  paralysed  muscles.  By  making  a  care- 
ful electrical  examination  in  such  cases  it  is  possible  to  determine 
whether  or  not  the  neurorrhaphy  has  been  successful. 

After-treatment  of  Tendon  and  Nerve  Sutures. — The  after-treatment 
of  neurorrhaphies  and  tenorrhaphies  consists  principally  in  placing  the 
affected  portion  of  the  body,  when  possible,  in  such  a  position  that  the 
suture  is  relaxed ;  for  example,  when  the  ulnar  or  median  nerve  has 
been  sutured  above  the  wrist  joint  the  hand  should  be  immobilised 
in  a  strongly  flexed  position  by  an  antiseptic  dres^ng,  made  possibly 
of  curved  wooden  splints,  or  of  a  properly  bent  wire  splint  like  that 
which  Cramer  advises.  The  remainder  of  the  after-treatment,  particu- 
larly in  neurorrhaphy,  is  very  important,  and  consists  in  the  use  of 
electricity,  massage,  and  methodical  exercise  of  the  affected  muscles. 

The  Procedures  when  a  Neurorrhaphy  is  Unsuccessful. — If  a  neuror- 
rhaphy should  partially  or  entirely  fail,  the  cicatrix  should  be  divided 
and  the  affected  portion  of  the  nerve  examined,  and,  if  possible,  the 
neurorrhaphy  should  be  repeated.  In  one  case  W.  Busch  exposed  the 
affected  part  of  the  nerve  ten  months  after  an  unsuccessful  neuror- 
rhaphy and  found  that  the  nerve  at  the  point  where  it  had  been 
sutured  was  encircled  by  connective  tissue  in  such  a  way  as  to  inter- 
rupt the  conduction  ;  he  freed  the  nerve  from  the  pressure  of  this  con- 
nective-tissue  cicatrix,    and   almost    immediately   the    nerve   became 


488    INJURIES  AND  SURGICAL   DISEASES  OP  THE  SOFT  PARTS. 

capable  of  conducting  the  induction  current,  and  directly  after  the 
operation  the  patient  could  perform  active  movements  which  had  pre- 
viously been  impossible.  Likewise  after  fractures  of  the  humerus  the 
musculo-spiral  nerve  is  sometimes  paralysed  by  the  pressure  of  the 
callus,  and  the  paralysis  may  disappear  immediately  after  removal  of 
this  pressure.  As  a  matter  of  fact,  it  is  well  known  that  the  conduc- 
tivity of  a  nerve  can  be  easily  destroyed  by  pressure. 

Spontaneous  Regeneration  of  the  Nerve  without  Suturing.— What  clinical 
facts  are  there  which  bear  upon  the  actual  restoration  of  conductivity  in 
nerves  which  have  been  divided  and  not  united  by  suturing  ?  The  observa- 
tions of  Weir  Mitchell,  Morehaus,  Keen,  and  others  prove  that  recovery 
takes  place  in  exceptional  cases  after  extensive  injuries  to  nerves  without  the 
nerve  stumps  being  united  by  sutures.  Notta  saw  one  instance  of  spontaneous 
regeneration  within  six  months  after  division  of  all  the  nerves  of  the  (uppei*) 
arm.  Tiedemann,  in  August,  1827,  exposed  the  brachial  plexus  of  a  dog  in 
the  axilla  and  divided  each  nerve,  excising  from  them  a  piece  two  to  two  and 
a  half  centimetres  long.  Complete  paralysis  of  sensation  and  motion  fol- 
lowed in  the  affected  extremity,  but  in  the  course  of  the  years  1827  and  1828 
sensation  and  motion  returned  entirely.  In  June,  1829,  the  dog  was  killed, 
and  it  was  found  that  the  ends  of  the  nerves  had  been  reunited  by  medullary 
nerve  fibres.  Schilf  excised  five  centimetres  of  the  vagus  nerve  in  a  dog, 
and  after  several  months  demonstrated  restoration  of  the  conductivity  of  the 
nerve  without  neurorrhaphy.  Langenbeck  and  Hueter  observed  a  restora- 
tion of  conductivity  after  laceration  of  the  brachial  plexus  in  a  Prussian 
oflBcer  who  was  wounded  by  a  cannon  ball  in  the  storming  of  the  Diippeler 
redoubt  on  April  18,  1864.  The  left  lung  was  extensively  injured,  and  the 
first  rib  was  shattered,  as  was  also  a  part  of  the  scapula  and  clavicle.  In 
spite  of  this  severe  injury  the  patient  escaped  with  his  life.  Langenbeck 
again  saw  the  patient  in  September  of  the  same  year,  and  his  arm  was  totally 
paralysed.  After  the  lapse  of  one  year  and  a  half  the  function  of  the  arm 
was  so  far  restored  by  electrical  treatment  that  the  patient  became  again  fit 
for  service,  and  served  as  an  officer  in  the  campaign  of  1866.  He  was  killed 
while  battalion  commander  in  the  battle  of  Worth.  Riedinger,  Krain,  Letie- 
vant,  and  others  have  also  observed  recoveries  after  nerve  division  without 
neurorrhaphy.  But  all  these  recoveries  are  rare  exceptions,  and  the  ordinary 
termination  is  irreparable  paralysis.  This  is  due  to  the  fact  that  the  nerve 
fibres  which  have  been  cut  off  from  their  centres,  as  we  remarked  before, 
perish  by  fatty,  granular  degeneration,  and  with  them  the  muscles  they 
supply. 

Results  of  Neurorrhaphy.— With  the  aid  of  my  own  and  Wolberg's  com- 
munications Weissensteiu  has  collected  seventy-six  cases  of  neurorrhaphy, 
and  he  believes  that  the  operation  has  been  successful  in  sixty-seven  per 
cent.  Among  the  seventy-six  cases  thirty-three  were  secondary  neuror- 
rhaphies, of  which  twenty-four  were  decidedly  successful  and  others  only 
partially  so.  The  return  of  sensibility  began,  for  the  most  part,  after  two  to 
four  weeks.  The  earliest  return  of  motility  began  after  sixteen  days,  but 
in  the  majority  of  the  cases  only  after  the  lapse  of  months,  and  twice  it 


§88.]  THE   TREATMENT   OF   WOUNDS   OF   SOFT   PARTS.  489 

required  a  year.  In  one  case  the  paralysed  muscles  regained  their  complete 
usefulness  after  twenty-six  days,  though  most  of  the  cases  took  a  year. 
Hodges  collected  104  cases  of  primary  neurorrhaphy  with  74  per  cent,  of 
cures,  and  108  cases  of  secondary  neurorrhaphy  with  80  per  cent,  of  cures. 

Regeneration  after  Complete  Division  of  Nerves.— The  regeneration  of  an 
injured  nerve  takes  place  essentially  as  follows :  When  a  nerve  has  been 
completely  divided,  regeneration  proceeds  from  the  central  end  towards  the 
periphery,  and  it  takes  place  the  more  rapidly  the  less  the  interval  between 
tlie  central  and  peripheral  nerve  stumps,  and  hence  most  rapidly  when  the 
stumps  are  united  by  sutures.  The  newly  developed  nerve  fibres  spring  from 
the  central  stump  of  the  old  nerve,  and,  bridging  over  the  defect,  unite  with 
the  peripheral  stump.  According  to  one  view,  the  old  nerve  fibres  of  the 
peripheral  segment,  after  their  separation  from  the  centre,  perish  irrevocably, 
and  the  newly  formed  nerve  fibres  from  the  central  end  grow,  analogously 
to  what  takes  place  in  embryonic  development,  along  the  peripheral  stump 
into  the  muscles  and  skin  (Vanlair).  According  to  another  view,  the  fibres 
of  the  peripheral  stump  do  degenerate,  but  after  the  regenerated  central  fibres 
have  entered  the  peripheral  stump  the  latter's  fibres  likewise  take  part  in  the 
regeneration  and  unite  with  the  fibres  growing  out  towards  them  from  the 
central  end.  Both  kinds  of  regeneration  may  occur  at  the  same  time,  and 
the  regeneration  of  the  degenerated  fibres  in  the  peripheral  stump  will 
take  place  the  more  rapidly  the  earlier  the  central  and  peripheral  ends  are 
united  by  sutures.  After  division  of  a  nerve  in  man  there  has  never  yet 
been  observed  a  direct  union  of  the  divided  nerve  fibres,  a  so-called  prima 
reunio,  with  restoration  of  conductivity  within  seventy  to  eighty  to  ninety 
hours,  as  Gluck  has  observed  it  in  animal  experimentation.  Kennedy  has 
also  observed  that  the  sutured  nerve  was  capable  of  conducting  impulses  a 
few  days  after  suture.  It  should  be  borne  in  mind  that  the  electrical  con- 
ductivity of  a  sutured  nerve  must  be  distinguished  from  its  real  regeneration 
at  the  point  of  suture  v/ith  restoration  of  function.  Regeneration  of  the 
place  of  suture  requires  time.  After  the  lapse  of  about  two  to  three  months, 
sometimes  later,  the  regeneration  of,  for  instance,  a  large  nerve  in  an  ex- 
tremity is  usually  completed.  If  the  nerve  stumps  are  not  united  by  suture, 
and  if  the  distance  between  the  central  and  peripheral  stumps  is  too  great, 
usually  no  regeneration  of  the  nerve  defect  occurs.  Under  these  conditions 
the  central  end  of  the  nerve  takes  on  a  club-shaped  enlargement  from  the 
formation  of  new  nerve  fibres  and  new  connective  tissue.  This  represents  an 
attempt  at  regeneration.  The  so-called  amputation  neuromata  are  also  ex- 
amples of  such  club-shaped  enlargements  of  the  ends  of  the  divided  nerves. 
In  the  most  rare  and  exceptional  instances  large  nerve  defects,  up  to  five 
centimetres  in  extent,  have  been  restored  in  man  and  animals  without  the 
nerve  being  sutured.  But,  as  a  general  thing,  the  experiments  of  Sticker  and 
others  show  that  spontaneous  regeneration  of  the  nerve  fails  when  the  dis- 
tance between  the  nerve  stumps  amounts  to  one  centimetre. 

Regeneration  after  Incomplete  Division  of  the  Nerve. — In  incomplete 
division  of  a  nerve,  in  contusions,  etc.,  regeneration  usually  takes  place  more 
rapidly.  If  the  conductivity  of  the  nerve  has  been  interrupted  by  compres- 
sion, such  as  would  be  exerted  by  a  bony  tumour,  by  a  callus,  etc.,  imme- 
diate restoration  of  the  power  of  conducting  a  nerve  current  has  been  observed 


490    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT  PARTS. 

upon  relieving  the  pressure.  A  regeneration  of  tlie  tissues  of  the  brain  and 
spinal  cord  never  takes  place  in  man.  But  Browu-Sequard  has  observed  a 
regeneration  of  a  divided  spinal  cord  in  doves. 

With  the  regeneration  of  the  nerves  the  excitability  of  the  latter  also 
returns,  and,  according  to  Erl>.  Ziemssen,  and  others,  the  power  of  conduction 
returns  sooner  than  the  local  excitability  ;  that  is,  muscular  contractions  will 
at  first  only  occur  when  stimulation  is  applied  above  the  point  of  injury,  and 
not  wlien  ap])lied  below. 

Histological  Changes  in  Nerve  Regeneration.— Opinions  vaiy  as  to  the 
changes  wliich  occur  in  the  regeneration  of  a  nerve.  In  all  cases  the  regen- 
eration begins  in  the  central  end.  About  the  third  week,  small,  pale  processes 
are  seen  projecting  from  the  .^xis  cylinders— i.  e.,  the  proximal  axis  cylinders 
become  prolonged ;  they  grow  outwards,  and  at  the  same  time  divide  into 
two  or  more  filaments.  These  newlj^  formed  nerve  filaments  become  longer 
and  longer,  and,  according  to  the  investigations  of  Vanlair  and  others,  they 
grow  into  the  skin  and  muscles.  The  young  nerve  fibres,  according  to  the 
views  of  various  authorities,  are  at  the  outset  naked  axis  cylinders,  and  then 
subsequently  become  covered  by  the  sheath  of  Schwann.  Tlie  statements 
made  by  some  authors,  that  the  young  nerve  fibres  are  formed  from  comiec- 
tive-tissue  cells  or  colourless  blood-corijuscles,  contradict  all  our  other  liisto- 
genetic  views.  According  to  Biingner,  Ziegler,  and  others  the  old  axis 
cylinder  does  not  take  part  in  the  regeneration,  but  the  new  fibi'es  are  formed 
bN-  differentiation  from  a  material  called  '"  neuroplasma,"  which  is  rich  in 
nuclei  and  originates  from  the  cells  of  the  sheath  of  Schwann.  These  cells 
are  thus  the  real  neuroblasts. 

The  investigations  of  many  authorities,  as  we  have  said,  show  that  analo- 
gous regenerative  changes  in  the  degenerated  fibres  also  take  place  in  the 
peripheral  nerve  stump,  but  much  later  than  in  the  central  stump.  The 
newly  developed  central  and  peripheral  nerve  fibres  grow  towards  each  other 
and  unite.  The  regenerative  changes  in  the  old  degenerated  fibres  in  the 
peripheral  nerve  segment  are  disputed  by  some  observers,  as  we  have 
remarked.  As  a  matter  of  fact,  it  is  ver}-  difficult  to  distinguish  histologically 
the  I'egeneration  and  degeneration  which  go  on  side  by  side  in  the  peripheral 
nerve  stump.  Mayer  has  made  the  important  observation  that  regenerative 
and  degenerative  changes  occur  even  in  perfectly  normal  nerves. 

Only  those  fibres  which  remain  connected  with  their  centres  are  capable 
of  regenerating  themselves.  The  so-called  regeneration  autogenique,  long 
insisted  upon  by  Yulpian— that  is,  the  independent  regeneration  of  a  portion 
of  nerve  cut  off  from  its  centre — is  founded  upon  an  error,  as  Vulpian  him- 
self has  admitted. 

The  works  treating  of  nerve  regeneration  are  very  numerous.  Cruik- 
shank,  experimenting  on  animals,  was  the  first  to  observe,  in  1776,  complete 
regeneration  of  divided  nerves.  Eeferences  to  the  most  important  literature 
on  the  subjects  of  nerve  injuries  and  neurorrliaphy  will  be  found  in  a  paper 
on  these  matters  in  the  Archiv  fiir  klin.  Chir.,  Bd.  xxvii. 

Further  Treatment  of  Wounds  of  Soft  Parts.— The  further  treatment 
of  wounds  of  soft  parts  consists  in  the  most  careful  disinfection  of  the 
wound  and  in  the  removal  of  any  foreign  body  which  has  entered  it, 


§88.]  THE   TREATMENT   OP  WOUNDS  OF   SOFT  PARTS.  491 

such  as  sand,  dirt  of  every  description,  pieces  of  glass,  points  of  instru- 
ments, bullets,  etc.  By  using  an  Esmarch  bandage  the  search  for  for- 
eign bodies  will  be  greatly  facilitated.  The  X  rays  can  be  used  to 
advantage  in  determining  the  location  of  foreign  bodies  (see  §  12-1,  Gun- 
shot Wounds).  We  shall  return  to  the  extraction  of  bullets  in  the 
chapter  on  Grunshot  Wounds.  The  removal  of  foreign  bodies  from 
the  internal  organs  and  the  large  cavities  of  the  body  is  discussed  in 
Regional  Surgery. 

When  the  treatment  of  the  wound  has  been  carried  out  in  the  man- 
ner described,  we  then  proceed,  in  the  case  of  large,  deep  wounds, 
to  provide  for  drainage  for  carrying  o£E  the  wound  secretion  (§  31). 
After  this,  in  proper  cases,  the  wound  is  closed  by  sutures  (§  33),  and 
an  antiseptic  dressing  is  applied  (§§  44—49).  All  fresh  wounds  which 
are  not  infected  or  markedly  contused  are  suitable  for  suturing.  If 
there  is  much  contusion  of  the  parts,  sutures  should  be  avoided, 
especially  on  the  skull,  where,  after  deficient  antisepsis,  a  retention  of 
the  secretion  from  the  wound  may  so  easily  become  dangerous  and 
lead  to  suppurative  phlebitis  with  secondary  fatal  meningitis.  If  the 
contusion  is  limited  simply  to  the  borders  of  the  wound  they  can  be 
excised  and  the  wound  then  closed  by  sutures.  In  all  cases  where 
there  is  doubt  about  the  propriety  of  suturing  the  wound,  it  is  prefera- 
ble to  omit  it  entirely  or  to  suture  only  partially — for  example,  in  the 
middle  of  the  wound. 

Indications  for  Amputation  or  Disarticulation. — Amputation  or  disarticu- 
lation is  indicated  in  fresh  cases  if  the  soft  parts  are  so  crushed  and  disinte- 
grated that  either  the  repair  of  the  injury  is  impossible,  or,  if  it  shoukl  occur, 
the  injured  limb  would  be  completely  useless.  Amputation  is  also  indicated 
in  cases  with  septic  cellulitis,  in  order  to  prevent  death  from  sepsis.  When 
amputation  has  to  be  performed  for  fresh  lacerated  and  contused  wounds,  it 
should  only  be  carried  out  in  sound,  normal  tissues,  and  not  within  the  limits 
of  the  contusion.  In  general,  operations  should  be  as  conservative  as  possi- 
ble, especially  those  upon  the  fingers.  If  all  the  fingers  have  to  be  removed 
and  the  thumb  only  can  be  saved,  this  should  be  done  in  every  case,  as  a 
movable  thumb  is  better  than  an  entire  artificial  hand.  In  the  tearing  away 
of  extremities  or  of  parts  of  them,  disarticulations,  amputations,  or  plastic 
operations  are  also  necessary  for  improving  the  stump  or  for  hastening 
recovery.  A  stump  of  bone  projecting  from  the  soft  parts,  after  the  latter 
have  been  torn  from  the  phalanges  of  the  fingers,  must  always  be  excised  or 
disarticulated  by  the  saw,  chisel,  or  bone  forceps  at  a  point  where  it  will  be 
•covered  by  soft  parts. 

Dressings,  packing  the  Wound,  etc. — The  best  aseptic  dressing  for 
sutured  aseptic  wounds  consists  of  sterile  gauze  and  cotton.  Small 
wounds  and  abrasions  of  the  skin  can  be  covered  with  different  kinds 
of  adhesive  plaster,  pastes,  collodion,  etc.     Small  uninfected  wounds 


402    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT  PARTS. 

closed  by  a  ernst  of  blood,  etc.,  will  heal  under  the  scab  without  a 
dressing.  Dusting-powders,  like  iodoform,  dermatol,  bismuth,  oxide 
of  zinc,  etc.,  are  suited  chiefly  for  unsutured  contused  wounds.  Pack- 
in  o-  with  aseptic  gauze  or  iodoform  gauze  is  particularly  applicable  for 
large  contused  and  lacerated  wounds,  with  or  %vithout  injury  to  bones, 
joints,  etc.  After  removal  of  the  aseptic  packing  the  wound  can  be 
closed  by  secondary  sutures,  or  the  packing  may  be  left  to  dry  and 
form  a  firm  aseptic  scab  upon  the  wound  until  it  falls  off  of  its  own 
accord.  In  suitable  cases — for  example,  in  extensive  contused  wounds — • 
antiseptic  irrigation  (§  49)  should  be  employed.  Under  certain  con- 
ditions it  is  an  excellent  plan  to  place  the  patient  in  a  permanent  water- 
bath  (§  49). 

I  must  refer  the  reader  to  §  22  and  §  62  for  the  treatment  of  the 
general  condition  of  those  who  have  been  injured. 

Treatment  of  Secondary  Haemorrhage. — Any  secondary  haemorrhages 
which  occur  during  the  healing  of  the  wound  are  to  be  arrested,  if  in 
an  extremity,  by  double  ligation  of  the  vessel  in  the  wound  with  the 
assistance  of  Esmarch's  bandage.  The  ligation  of  the  principal  artery 
in  its  continuity  above  the  wound,  at  the  so-called  place  of  election,  is 
only  to  be  recommended  when  the  application  of  Esmarch's  bandage 
is  impossible  and  the  blood  wells  out  from  the  depths  of  the  wound  in 
such  amounts  that  there  is  danger  of  the  patient's  bleeding  to  death. 
In  such  critical  conditions  an  assistant  should  stop  the  haemorrhage  by 
pressure  with  the  finger  in  the  wound  while  the  main  artery  is  rapidly 
secured  at  some  easily  accessible,  centrally  situated  point.  The  wound 
can  then  be  examined  more  leisurely  and  the  injured  vessel  tied  in  the 
wound  by  a  double  ligature.  The  leaving  in  place  of  artery  forceps,  a 
firm  packing  of  the  wound  ^vith  iodoform  gauze,  dressings  which  exert 
pressure,  digital  compression,  etc.  (^§  28  and  29),  have  also  rendered 
excellent  service  in  cases  of  secondary  haemorrhage  from  deeply  located 
regions,  where  the  application  of  a  ligature  is  impossible  or  difficult. 

Suppuration — Burrowing  of  Pus. — During  the  healing  of  the  wound^ 
especially  if  it  is  a  large  contused  or  suppurating  wound,  one  must 
always  guard  against  any  burrowing  of  pus.  If  spreading  inflamma- 
tion and  suppuration  are  already  present  in  the  wound  when  it  comes 
under  observation,  as  many  incisions  as  are  required  should  be  made, 
as  described  in  §  70  (cellulitis).  The  treatment  of  complications  of 
infected  wounds,  including  the  infectious-wound  diseases,  is  discussed 
in  §§  62-82. 

Every  wound  until  it  has  cicatrised  should  be  treated  strictly  ac- 
cording to  antiseptic  rules ;  these  should  never  be  neglected,  especially 
during  a  change  of  dressings.      In  the  later  stages  of  repair  in  the 


§89.]  TREATMENT   OF  H.EMOREHAGES.  493 

wound,  especially  when  it  is  granulating,  ointment  dressings  are  to  be 
employed  (§  49).  The  final  skinning  over  of  a  granulating  wound  is 
often  hastened  by  the  occasional  use  of  the  nitrate-of -silver  stick.  By 
this  cauterisation  with  argent,  nitrat.  we  make  the  shrinkage  of  the 
granulation  tissue  more  rapid  and  prevent  it  from  growing  too  luxuri- 
antly. We  cover  extensive  losses  of  substance  in  the  skin  with  trans- 
planted skin  (§  42),  or  by  plastic  operations  (§  41),  etc.  The  formation 
of  cicatricial  contractures  is  always,  as  far  as  possible,  to  be  prevented ; 
but  if  contractures  do  nevertheless  develop,  they  should  be  treated  in 
the  manner  described  on  pages  146,  305,  and  in  §  119. 

For  finding  metallic  foreign  bodies  which  have  become  healed  up  in  a 
wound  the  magnetic  needle  has  been  used  with  success.  By  its  deviations  it 
can  indicate,  for  example,  the  location  of  a  needle  which  has  become  healed 
up  in  the  wound  (Kocher.  etc.).  Also  for  finding  bullets  which  have  healed 
in,  the  magnetic  needle  can  be  used  with  advantage,  particularly  in  army 
surgery  (see  §  124).  The  X-rays  are  also  used  a  great  deal  in  locating  foreign 
bodies. 

§  89.  Treatment  of  the  Conditions  Following  Severe  Hsemorrhage — 
Blood  and  Common  Salt  Infusion. — If,  after  an  injury  to  large  arteries 
or  veins,  the  haemorrhage  has  been  considerable,  the  general  weak  con- 
dition of  the  patient  very  often  demands,  after  arrest  of  the  bleeding, 
the  adoption  of  special  measures  which  must  be  carried  out  rapidly 
and  energetically.  In  the  milder  cases  of  swooning  after  loss  of  blood, 
the  head  should  be  placed  as  low  as  possible,  the  face  of  the  patient 
sprinkled  with  water,  olfactory  stimulants,  such  as  ammonia,  adminis- 
tered, as  well  as  several  hypodermic  injections  of  ether  ;  the  patient 
should  be  placed  as  soon  as  possible  under  warm  coverings  and  sur- 
rounded by  hot  bottles,  sand-bags,  and  the  like,  besides  being  rubbed 
with  towels  and  stimulated  with  strong  wine,  cognac,  black  coffee,  etc. 
It  is  also  a  very  excellent  plan  to  supply  a  patient  who  has  lost  a  large 
amount  of  blood  with  great  quantities  of  heated  fluids ;  they  are  ab- 
sorbed from  the  gastro-intestinal  tract  more  rapidly  than  under  normal 
conditions,  and  are  a  direct  means  of  making  good  the  blood  deficiency. 
In  severe  cases  the  lowering  of  the  head  should  be  combined  with 
elevation  of  the  legs,  or,  better,  with  the  envelopment  of  the  legs  in 
an  elastic  bandage,  in  order  to  prevent  the  threatening  cerebral  anaemia 
and  to  drive  the  blood  out  of  the  extremities  towards  the  heart,  the 
lungs,  and  the  brain  (autotransfusion).  In  the  cases  of  very  extreme 
anaemia  all  the  above-mentioned  remedies  will  be  of  no  avail  in  keep- 
ing the  patient  alive,  and  the  only  other  remedy  that  offers  any  hope 
is  the  transfusion  or  infusion  of  blood  or  a  sterilised  physiological 
solution  of  sodium  chloride. 


494    IXJ  CRIES  AND  SURGICAL  DISEASES   OF   THE   SOFT   PARTS. 

Transfusion  of  Blood  used  to  be  very  frequently  practised  for  tlireat- 
ening-  death  from  luTjmorrliuge,  for  poisoning  hj  illuminating  gas,  car- 
bonic oxide,  carbonic  acid,  for  septicaemia,  and  for  various  internal  dis- 
eases. At  present  the  belief  in  tlie  capabilities  of  transfusion  lias  been 
given  up,  and  the  operation  is  but  rarely  performed.  With  the  increas- 
ing knowledge  of  the  physiology  and  pathology  of  the  Ijlood,  we  have 
found  that  the  earlier  views  and  presumptions  which  lay  at  the  founda- 
tion of  blood  transfusion  were  false.  I  fully  agree  with  Bergmann. 
and  others  who,  reasoning  from  physiological  facts,  consider  transfusion 
not  only  a  useless,  but  also,  as  we  shall  see,  a  dangerous  operation. 

Causes  of  Death  from  Haemorrhage. — The  cause  of  death  from 
haemorrhage  used  to  be  ascribed  to  the  loss  of  red  blood -corpuscles, 
and  hence  to  the  impoverishment  of  the  blood  in  hsemoglobin,  or 
rather  in  oxygen.  But  now  we  know  that  death  from  hsemoi-rhage 
is  dependent  upon  purely  mechanical  conditions.  It  is  caused  by  the 
insufficient  filling  of  the  vascular  system,  by  the  fall  of  the  arterial 
blood  pressure,  or,  in  other  words,  by  the  purely  mechanical  dispropor- 
tion between  the  capacity  of  the  vascular  system  and  the  amount  of 
its  contents.  For  this  reason  the  movement  of  the  contents  of  the 
vessels  ceases ;  the  heart,  which  at  first  continues  to  beat,  is,  like  an 
empty  pump,  no  longer  able  to  raise  the  column  of  blood  and  drive  it 
onwards.  Hence  in  such  cases  the  indication  is  to  increase  the  con- 
tents of  the  vascular  system  by  infusion  of  some  liquid,  and  for  this 
purpose  the  blood  of  man  or  animals,  in  its  entirety,  or  defibrinated 
human  blood,  used  to  be  employed ;  but  recently  the  infusion  of  an 
alkaline  seven-tenths-per-cent.  solution  of  common  salt  has  been  largely 
substituted  for  blood  transfusion  (Kronecker,  Sander,  etc.). 

Infusion  of  a  Coinmon  Salt  Solution. — As  a  matter  of  fact,  infusion  of 
common  salt  is  better  than  blood  transfusion,  and  I  should  always  use 
it  in  cases  of  acute  anaemia.  The  recent  reports  of  Cavazzani,  Pors- 
tempski,  and  others,  which  favour  blood  transfusion,  do  not  influence 
my  views  in  the  least.  Landerer,  at  the  suggestion  of  C.  Ludwig  and 
Gaule,  has  proposed  the  addition  of  three  to  five  per  cent,  of  sugar  to 
the  alkaline  (0.7  per  cent.)  solution  of  common  salt.  The  advantage  of 
the  salt-sugar  solution  over  the  plain  salt  solution  consists,  according  to 
Ludwig,  in  the  fact  that  the  former  is  to  be  regarded  as  a  nutritive  solu- 
tion, and  that,  in  consequence  of  its  high  endosmotic  equivalent,  blood 
which  contains  sugar  takes  up  the  parenchymatous  fluids  more  ener- 
getically ;  moreover,  the  blood  pressure  rises  more  rapidl}^,  and  the  red 
blood-corpuscles  are  more  apt  to  remain  intact  than  when  a  pure  salt 
solution  is  employed.  It  is  simplest  to  infuse  the  salt  solution  subcu- 
taneously  (pages  498,  499). 


§89.]  TREATMENT   OF  H^MOERHAGE.  495. 

Dangers  of  Blood  Transfusion,— That  the  transfusion  of  blood  in  any  form 
is  not  only  a  useless  but  also  a  dangerous  operation,  the  following-  statements 
prove.  In  the  first  place,  we  know  from  the  experiments  made  by  Miiller 
and  Lesser,  under  the  guidance  of  C.  Ludwig,  that  all  the  red  blood-corpuscles 
injected  with  the  blood  are  destroyed  in  a  few  days.  The  corresponding^ 
hcemoglobinuria  which  accompanies  this  process  is  caused  by  the  disintegra- 
tion of  the  red  corpuscles,  or,  rather,  by  the  separation  of  the  haemoglobin 
from  the  stroma  of  the  red  corpuscles,  allowing  free  haemoglobin  to  circulate 
in  the  blood.  According  to  Sachsendahl,  the  dissolved  haemoglobin  is  the 
most  powerful  agent  for  bringing  about  a  rapid  destruction  of  the  colourless 
blood-corpuscles  and  a  very  sudden  and  marked  accumulation  of  the  fibrin 
ferment  in  the  circulating  blood,  so  that  death  may  occur  from  ferment 
intoxication. 

Magendie  uttered  a  warning  against  the  use  of  defibrinated  blood,  because 
its  injection  was  followed  by  very  definite  disorders,  such  as  rapid  respira- 
tion, diarrhoea,  bloody  transudations  into  the  peritonaeum,  the  pleura  and 
pericardium,  and  even  by  death.  The  interesting  investigations  of  Armin 
Kohler  show  the  possibility  of  ferment  intoxication  after  blood  transfusion. 
He  demonstrated  that  blood  taken  from  another  species,  as  well  as  blood 
from  the  same  species,  had  a  poisonous  action.  If  only  ten  to  twelve  cubic 
centimetres  of  blood  were  drawn  from  the  carotid  of  a  strong  rabbit,  allowed 
to  coagulate,  and  the  blood  coagulum  then  chopped  up,  pressed  between 
pieces  of  linen,  filtered,  and  of  this  defibrinated  blood  only  five  to  six  cubic 
centimetres  were  injected  slowly  into  the  internal  jugular  vein  of  the  same 
animal,  it  usually  died  during  the  injection,  from  extensive  coagulation  in 
the  right  heart  and  in  all  the  branches  of  the  pulmonary  artery  in  both, 
lungs.  These  facts  are  explainable  upon  Schmidt's  theory  of  coagulation. 
The  fibrino-plastic  substance,  and  particularly  the  fibrin  ferment,  are  found 
free  in  blood  defibrinated  in  the  above  manner,  and  being  carried  in  this 
state  into  the  circulating  blood  they  excite  within  the  blood  channels  exten- 
sive thromboses.  The  animal  dies  in  consequence  of  the  ferment  intoxica- 
tion. Pepsin  and  pancreatin  have  an  effect  analogous  to  the  blood  ferment 
(Bergmann,  Angerer).  Blood  defibrinated  by  beating  or  shaking,  according 
to  the  old  method  of  blood  transfusion,  is  not  by  any  means  as  rich  in  the 
fibrinoplastic  substance  and  in  the  fibrin  ferment  as  blood  which  has  been 
pressed  in  the  manner  just  described,  but  it  is  only  a  difference  in  quan- 
tity ;  consequently  Kdhler  is  right  in  considering  blood  which  has  been  defi- 
brinated by  whipping  not  so  harmless  as  has  been  hitherto  supposed.  As 
regards  the  histocym  isolated  from  the  blood  by  Schmiedeberg,  see  page  313. 

Transfusion  of  Animal  Blood. — In  the  transfusion  of  blood  taken  from 
another  species  of  animal  still  other  conditions  come  into  consideration. 
Partly  as  a  result  of  chemical  action  and  partly  as  a  result  of  the  above- 
mentioned  disintegration  of  the  red  blood-corpuscles,  the  blood  of  a  sheep, 
for  example,  is  a  fatal  poison  for  a  dog  if  injected  in  sufficient  amount  into 
the  vascular  system  of  the  latter ;  and  again,  a  dog's  blood  is  just  as  poison- 
ous for  a  sheep.  After  the  direct  introduction  of  lamb's  or  dog's  blood  into 
the  veins  of  a  man,  dangerous  symptoms  had  been  observed  more  than  two 
hundred  years  ago,  and  yet  about  fourteen  years  ago  an  attempt  was  made  to 
reintroduce  the  transfusion  into  man  of  lamb's  blood.     Chills,  fever,  haamo- 


496    INJURIES  AXD   SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 

globinuria,  as  a  result  of  the  disintegration  of  the  red  corpuscles  in  the  cir- 
culating- blood,  and  not  infrequently  death,  were  the  consequences.  Panuni, 
Landois,  and  Pontick  have  proved  by  numerous  experiments  the  dangers  *)f 
the  transfusion  of  animal  blood  into  man,  and,  in  fact,  the  danger  of  trans- 
fusion of  blood  in  any  form  which  has  been  taken  from  another  species.  We 
shall  now  always  be  on  our  guard  against  a  return  to  the  transfusion  of  ani- 
mal blood. 

Direct  Blood  Transfusion.— It  would  be  most  advantageous  if  the  blood  in 
its  entirety-  could  be  conducted  from  the  artery  of  a  man  into  the  vein  of  the 
receiver.  But  all  kinds  of  difficulties  stand  in  the  way  of  employing  this 
direct  transfusion.  It  is  not  so  easy  to  find  any  one  w^ho  will  give  blood 
directly  from  an  artery  as  one  who  will  give  it  from  a  vein.  Then,  the  pos- 
sibility of  the  blood  coagulating  in  the  conducting  tube  must  be  taken  into 
consideration.  Furthermore,  it  is  always  questionable  whether  tlie  corpus- 
cles retain  their  vitality  in  the  blood  of  the  receiver. 

Wright  and  Hertig  have  recommended  decalcified  blood  for  transfusion, 
as  Arthus  and  Pages  found  that  it  did  not  coagulate  (see  page  297). 

As  a  substitute  for  the  inti'oduction  of  blood  into  the  vascular  system, 
Ponfick  has  recommended  intra-peritoneal  transfusion — i.  e.,  the  infusion  of 
defibrinated  blood  into  the  peritoneal  cavity.  The  clinical  and  experimental 
investigatioias  of  Angerex-,  Edelberg,  and  others  have  taught  that  this  method 
should  be  condemned. 

Ziemssen  has  employed  with  advantage  in  chronic  anaemia  the  subcuta- 
neous injection  of  defibrinated  blood  at  a  tempei'ature  of  37°  to  40°  C  into  the 
subcutaneous  tissue  of  the  thigh,  using,  for  example,  three  hundred  and  fifty 
grains  in  about  fourteen  injections.  For  acute  anaemia  Ziemssen  and  others 
recommend  the  subcutaneous  injection  of  a  sterilised,  physiological,  seven- 
tenths-per-cent.  solution  of  common  salt. 

Indications  for  Infusion  of  Blood  and  Sodium  Chloride.— The  indications 
for  undertaking  blood  or  common  salt  infusion  are  most  frequently  a  high 
grade  of  anaemia  after  loss  of  blood,  and  poisoning  by,  for  example,  carbonic- 
oxide  gas  and  illuminating  gas,  in  which  common  salt  infusion  has  also 
repeatedly  proved  efficacious.  The  operation  is  no  longer  employed  for  sep- 
ticiemia  or  chronic  diseases  of  the  blood  (chlorosis,  leucocythasmia,  pernicious 
ana?mia,  etc.).  nor  for  chronic  marasmus. 

General  Technique  of  Blood  and  Common  Salt  Infusion.— The  transfusion 
is  performed  wuth  local  anaesthesia  in  order  that  the  behaviour  of  the  patient 
during  the  infusion  can  be  more  accurately  observed.  The  operation  is  not 
painful,  and  very  of  ten  the  patients  are  uncon.scious.  During  the  transfu- 
sion of  blood  a  greater  or  less  amount  of  dyspnoea  and  cyanosis  is  u.sually 
observed,  and  both  manifestations  not  iiifrequently  become  so  pronounced 
that  the  operation  has  to  be  .suspended.  Furthermore,  if  syncope  occurs  the 
infusion  should  be  immediately  stopped. 

Technique  of  the  Transfusion  of  Venous  Blood,— In  venous  transfusion 
with  defibrinated  liuman  blood,  about  two  liundred  to  four  hundred  grammes 
of  blood  are  drawn  from  a  vein  of  a  strong  man  into  a  carefully  disinfected 
glass  vessel.  The  blood  is  heated  on  a  water  bath  to  about  39°  to  40°  C. 
(102.2°  to  104°  F.).  defibrinated  by  whipping  with  a  clean  glass  rod,  then  fil- 
tered through  clean  linen  in  a  glass  funnel  into  another  glass  vessel  kept  at 


§  89.]  TREATMENT   OF   HEMORRHAGE.  497 

about  39°  to  40°  C.  (102.2°  to  104°  F.)  over  a  water  bath.  While  an  assistant 
attends  to  the  defibrination  and  filtration  of  the  blood,  a  large  cutaneous  vein 
— usually  at  the  elbow — is  picked  out.  The  finding  of  the  vein  can  be  facili- 
tated by  causing  it  to  become  distended  with  a  phlebotomy  bandage  wound 
around  the  (upper)  arm.  After  exposing  the  vein  and  isolating  some  2.3 
centimetres  of  its  extent,  two  catgut  ligatures  are  passed  under  it,  and  the 
vein  is  gently  lifted  with  the  peripheral  ligature  and  opened  by  scissors. 
A  disinfected  glass  cannula  is  pushed  into  the  open  vein  in  the  direction  of 
the  blood  current  and  secured  by  the  other  ligature.  The  bleeding  from  the 
vein  is  checked  simply  by  lifting  the  vein  by  the  peripheral  ligature,  or  the 
latter  may  be  knotted.  The  glass  cannula  is  filled  with  blood,  and  then  the 
warm  defibrinated  blood  is  injected  by  a  glass  syringe,  which  is  not  too  large, 
or  a  glass  jar  is  used  with  a  rubber  tube  like  an  irrigator.  About  two  hun- 
dred to  three  hundred  grammes  are  injected  slowly  ;  Hueter  recommends  the 
injection  of  four  hundred  grammes  or  more.  The  entrance  of  air  into  the 
vein  and  the  formation  of  coagula  are  especially  to  be  avoided.  The  strict- 
est asepsis  as  regards  the  giver  and  receiver  of  the  blood  must  always  be 
observed. 

Technique  of  Arterial  Blood  Transfusion. — In  arterial  transfusion  (Grafe, 
Hueter)  the  radial  or  ulnar  artery  is  exposed  and  sufficiently  isolated  above 
the  wrist  joint.  Three  catgut  ligatures  are  then  pushed  under  the  artery. 
The  centrally  located  ligature  is  knotted  and  occludes  the  artery,  while  a 
simple  knot  or  sling  is  made  with  the  peripheral  ligature,  or  the  vessel  is 
■closed  temporarily  with  a  small  artery  clamp.  The  artery  is  then  opened 
with  scissors  between  the  two  ligatures  or  on  the  proximal  side  of  the  periph- 
erally placed  artery  clamp,  a  glass  tube  is  pushed  into  the  hole  in  the  artery 
towards  the  periphery  and  firmly  secured  with  the  third  ligature.  The  fur- 
ther course  of  the  operation  is  the  same  as  above. 

After  the  termination  of  the  transfusion  the  artery  and  vein  are  tied  cen- 
trally and  peripherally,  the  intervening  portion  used  for  the  infusion  is  extir- 
pated, and  the  glass  cannula  removed.  Hueter  claims  that  the  advantage  of 
arterial  transfusion  lies  in  the  fact  that  the  blood  is  first  driven  into  the  capil- 
laries, and  the  latter  act  as  a  filter  for  any  clot  that  may  be  injected ;  there 
is,  moreover,  no  danger  from  the  entrance  of  air. 

Technique  of  Direct  Blood  Transfusion. — In  the  direct  conduction  of  blood 
from  an  artery  into  a  vein  the  above  rules  are  followed— i.  e.,  a  glass  cannula 
is  tied  into  the  vein  of  the  receiver  and  one  into  the  artery  of  the  giver  of 
the  blood,  and  both  are  connected  by  a  rigorously  disinfected  rubber  tube  in 
which  a  glass  tube  is  sometimes  interposed  to  control  any  coagulation. 

Technique  of  Salt  Infusion.— In  the  infusion  of  salt  solution,  which  should 
he  undertaken  as  soon  as  possible  after  the  haemorrhage  and  with  the  strict- 
est asepsis,  a  sterilised  seven-tenths-per-cent.  solution  of  common  salt  warmed 
to  about  39°  C.  (102.2°  F.)  is  used,  which  is  rendered  alkaline  by  the  addition 
of  sodium  hydroxide  or  potassium  carbonate.  Szuman  recommends  aq.  destil. 
1,000,  sod.  chlorat.  6.0,  sod.  carb.  1.0.  For  one  to  one  and  a  half  litres  of  a 
seven-tenths-per-cent.  solution  of  common  salt  about  three  drops  of  sodium 
hydrate  are  sufficient.  According  to  Kronecker,  the  solution  of  salt  should 
be  0.73  per  cent,  and  7ieutral— alkaline  liquids  may  prove  dangerous- or  the 
above-mentioned  salt-sugar  solution  of  Ludwig's  may  be  used.  For  infu- 
35 


498    INJURIES  AND  SURGICAL   DISEASES  OF  THE   SOFT   PARTS. 


sion,  a  glass  funnel  is  employed,  or  a  glass  flask  with  a  tube  at  the  bottom 
connecting  it  with  a  rubber  tube  and  a  glass  cannula.  The  infusion  should 
take  place  under  no  higher  pressure  than  exists  in  the  large  veins.  Jacob- 
son  states  that  this  is  represented  at  the  most  by  one  centimetre  of  mercury 
or  thirteen  centimetres  of  the  sodium-chloride  solution— i.  e.,  the  infusion 
flask  should  not  be  held  higher  than  0.13  to  0.25  millimetre  above  the  open- 
ing in  the  vein.     During  the  infusion  the  body,  especially  the  abdominal 

viscera,  should  be  vigorously  mas- 
saged. Five  hundred  cubic  centi- 
metres at  the  least  are  injected, 
and  in  severe  cases  of  htemor- 
rhage  about  one  thousand  to  fif- 
teen hundred  cubic  centimetres. 
The  infusion  should  not  be  car- 
ried on  too  rapidly,  about  sixty  ta 
ninety  cubic  centimetres  being  in- 
jected in  a  minute.  The  success 
of  salt  infusion  has  so  far  been 
very  encouraging.  The  venous  in- 
fusion, according  to  the  experience 
we  have  had  with  it,  should  be 
preferred  to  the  arterial. 

Kiimmel  likewise  warns  against, 
infusing  salt  solution  into  an  ar- 
tery. After  the  infusion  with  a. 
glass  syringe  of  about  five  hun- 
dred grammes  of  a  six-tenths-per- 
cent, alkaline  salt  solution  into 
the  radial  artery,  gangrene  of  the 
skin  followed,  rendering  it  neces- 
sary to  amputate  the  forearm  be- 
tween the  lower  and  middle  thirds. 
Subcutaneous  Salt  Infusion.— 
According  to  my  own  experience, 
the  subcutaneous  infusion  of  a 
^^^  sterilised  seven  -  tenths  -  per  -  cent, 
solution  of  common  salt  is  exceed- 
"igly  good.  The  investigations  of 
Ziemssen,  Samuel,  etc.,  have  dem- 
onstrated that  the  system,  even 
when  the  activity  of  the  heart  is 
impaired,  is  still  able  to  take  up 
into  its  circulation  great  quan- 
tities of  salt  solution  injected  subcutaneously.  It  is  injected  through  a 
hollow  needle  into  various  parts  of  the  body,  particularly  beneath  the  skin 
over  the  abdomen,  by  means  of  some  apparatus  like  that  of  Sahli's,  illustrated 
in  Fig.  .360 ;  five  hundred  to  one  thousand  cubic  centimetres,  warmed  to  .39° 
C.  (102.2°  F.),  are  injected  during  five  to  ten  to  fifteen  to  twenty  to  thirty 
minutes,  according  to  the  nature  of  the  case,  and  absorption  is  hastened  by 


Fig.  3(30. — Apparatus  for  the-  ^ubeutanL-ous  infusion 
of  a  -saline  solution,  consisting  of  a  glass  vessel 
with  a  rubber  stopper  having  three  holes ;  a 
thermometer  (  Th),  a  rubber  tube  with  an  in- 
terposed glass  tube,  a  stop-cock  (§j,  and  a  hol- 
low needle. 


§  90.]  BURNS.  499 

gentle  rubbing  (massage).  I  have  seen  remarkable  results  in  acute  anaemia, 
and  in  collapse  after  prolonged  operations  on  weak  individuals.  In  proper 
cases  several  litres  of  salt  solution  can  be  injected  subcutaneously  on  several 
different  days.  In  one  patient  with  chronic  mercurial  poisoning  Sahli 
washed  out  the  body,  as  it  were,  with  twenty-one  litres  of  salt  solution  in 
eight  sittings ;  each  time  two  and  a  half  to  four  litres  were  infused  subcu- 
taneously. However,  a  therapeutic  success  was  not  obtained,  since  the  mer- 
cury could  not  be  demonstrated  in  the  urine.* 

Infusion  of  "Warm  Water. — In  one  case  Coates  made  a  successful  injection 
of  six  hundred  and  fifty  grammes  of  pure  warm  water  into  the  cephalic  vein. 

Milk  Infusion. — At  the  end  of  the  eighteenth  century  Muralto  recom- 
mended the  injection  of  milk  instead  of  blood.  But  Landois  and  others 
have  shown  by  animal  experimentation  that  the  procedure  is  to  be  con- 
demned as  directly  dangerous  to  life  ;  its  results  are  marked  disturbances  of 
circulation,  coagulation,  and  emboli.  Vigezzi  has  recently  tested  experi- 
mentally the  infusion  of  milk  into  veins,  and  he  states  that  acidified  milk 
brings  about  the  above-mentioned  dangerous  manifestations,  but  that  milk 
mixed  with  an  alkaline  solution  is  entirely  harmless. 

§  90.  Burns. — Burns  originate  in  a  great  many  different  ways — 
e.  g.,  by  direct  contact  of  the  affected  portion  of  the  body  with  a  flame, 
or  by  the  explosion  of  powder,  illuminating  gas,  "fire-damp,"  etc. 
Fire-damp  occurs  in  coal  mines  in  particular,  and  causes  an  explosion 
if  mixed  with  a  double  volume  of  oxygen  or  a  tenfold  volume  of  air 
and  brought  in  contact  with  a  flame.  Burns  are  very  often  due  to  the 
action  of  hot  gases,  steam,  liquids,  hot  solid  bodies,  such  as  metals,  etc. 
In  this  class  of  cases  belong  the  injuries  caused  by  caustic  substances, 
such  as  concentrated  acids  (sulphuric  acid,  nitric  acid,  etc.),  and  by 
caustic  alkalies.  Comparatively  mild  burns  of  the  skin  are  caused  by 
the  sun's  rays. 

Symptoms  and  Course  of  Burns. — The  clinical  course  of  a  burn  de- 
pends upon  its  intensity  and  extent.  The  intensity  of  the  burn  is  con- 
ditional upon  the  degree  of  the  heat  and  the  duration  of  its  action. 
The  purely  local  manifestations  may  occur  in  three  different  degrees  of 
severity  :  First  degree,  hyjyermmia  ;  second  degree,  hleb  formation  / 
third  degree,  eschar  formation. 

Burns  of  the  First  Degree. —  The  first  degree  is  characterised  by  a 
painful  redness  and  slight  swelling  of  the  skin — i.  e.,  by  a  dilatation  of 
the  capillaries,  with  a  slight  exudation  of  serum,  as  in  erythema,  or  in 
a  mild  inflammation.  In  the  mildest  cases  the  redness  disappears  in  a 
short  time  and  nothing  follows.  Very  frequently  the  horny  layer  of 
epidermis  is  cast  off  in  the  form  of  small  scales  or  patches.  In  the 
second  degree  of  burn  we  observe,  in  addition  to  the  manifestations  of 
the  first  degree,  the  development  of  small  and  large  hlebs,  which  are 

*  Sahli,  Samml.  klin.  Vortr.,  N.  F.,  No.  11. 


500    INJURIES  AND  SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 


tilled  with  a  watery,  transparent,  or  slightly  yellow  serum,  and  here 
and  there  with  serum  mixed  with  blood.  These  blebs  either  develop 
immediately  or  in  the  course  of  the  next  few  hours  after  the  reception 
of  the  burn.  The  blebs  are  usually  located  in  the  epidermis,  and  their 
contents  raise  the  horny  layer  from  the  underlying  layer  of  the  rete 
Malpighii.  The  rapid  development  of  the  blebs  in  a  burn  has  not  yet 
been  clearly  explained.  In  burns  of  this  second  degree  the  swelHng 
and  pain  are  usually  very  considerable,  especially  at  those  points  where 
there  is  much  tension,  or  when  the  blebs  are  removed  and  the  very 
sensitive  reddened  corium  is  exposed  to  the  air.  If  the  blebs  break  or 
are  artificially  opened,  the  epidermis  beneath  the  portion  that  has  been 
lifted  up  forms  a  new  horny  layer  within  three  to  six  to  eight  days, 
and  from  this  the  shreds  of  the  old  horny  layer  can  be  easily  removed. 
If  the  true  cntis  is  exposed,  or  if  the  latter  is  involved  in  the  burn,  sup- 
puration often  ensues  ;  but  it  can  be  entirely  prevented  by  antiseptic 
dressings,  after  previously  carefully  disinfecting  the  parts.  These  lat- 
ter cases  form  the  transition  to  burns  of  the  third  degree^  in  which,  as 

a  result  of  the  action  of  very  severe 
heat,  an  eschar  is  formed.  The  appear- 
ance of  the  eschar  varies  greatly,  being 
ashy  grey,  brown,  yellow,  or  black  in 
colour,  and  either  moist  or  dry.  The 
separation  of  the  eschar  is  brought 
about  by  the  ensuing  suppuration, 
which  can  be  limited  or  prevented  by 
antiseptic  treatment.  In  burns  of  the 
third  degree  the  difference  between 
individual  cases  is  very  great,  and  they 
include  burns  varying  from  a  partial 
destruction  of  the  cutis  to  a  complete 
carbonisation  of  an  entire  extremity. 
Hence  it  follows  that  the  division  of 
burns  into  three  degrees  is  somewhat 
illusory,  and  there  have  been  surgeons  who  have  distinguished  seven 
to  ten  deo-rees  of  burns.  But  the  division  of  burns  into  three  degrees 
is,  on  the  whole,  the  best. 

The  casting  off  of  the  burned  tissue  occasionally  takes  a  very  long 
time,  especially  when  bones  are  involved.  When  the  eschar  has  been 
removed,  and  a  correspondingly  large  granulating  wound  surface  has 
taken  its  place,  the  skin  gradually  forms  over  it,  as  described  in  §  61. 
A  very  extensive  destruction  of  skin  is  often  observed  after  burns, 
causing  great  obstacles  to  repair.     The  cicatrix  not  infrequently  gives 


Fig.  361. — Cicatrix  resulting  from  a  burn 
with  boilincr  water,  observed  in  a  boy 
live  years  old. 


§  90.]  BURNS.  501 

rise  to  various  disturbances  of  function  and  to  deformities,  among 
which  mention  should  be  made  of  ectropion  of  the  eyelids,  adhesion  of 
the  chin  to  the  chest,  contractures  of  joints  in  the  extremities,  etc. 
(Fig.  361).  These  cicatricial  contractures  are  best  prevented  bj  the 
transplantation  of  large,  fresh  cutaneous  flaps  with  pedicles,  or  by  stin 
grafting. 

Constitutional  Symptoms  after  a  Burn. — The  constitutional  symptoms 
observed  after  the  reception  of  a  burn  depend  in  the  first  place  upon 
the  extent  of  the  burn.  It  is  generally  accepted  that  when  more  than 
half  the  surface  of  the  body  is  burned  even  to  a  slight  extent  death  is 
certain  to  follow ;  in  many  cases  death  ensues  when  the  burn  involves 
only  a  third  of  the  body.  The  carbonisation  of  an  extremity  is,  in 
general,  better  borne  than  an  extensive  slight  burn  of  the  surface  of 
the  body.  After  extensive  burns  death  ensues  either  immediately  after 
the  injury  or  in  the  course  of  the  first  or  second  day,  or  after  several 
days  or  weeks — i.  e.,  either  in  the  stage  of  inflammatory  reaction,  or 
in  that  of  suppuration  and  exhaustion. 

Immediately  after  the  reception  of  an  extensive  burn  the  patient  is 
usually  in  a  state  of  great  excitement ;  he  complains  of  severe  pain  in 
the  injured  part,  and  often  cries  and  screams.  The  mind  is  at  first  en- 
tirely clear.  In  the  cases  running  a  rapidly  fatal  course  the  patients 
are  very  restless  and  toss  about  in  bed ;  delirium  and  convulsions  come 
on,  the  thready  pulse  is  extremely  rapid,  the  temperature  of  the  body 
is  below  normal — sometimes  as  much  as  3°  to  5°  F. — the  respiration  is 
superficial  and  rapid,  the  extremities  are  cool,  and  death  usually  follows 
with  increasing  symptoms  of  collapse  and  coma.  The  lowering  of  the 
temperature  occurring,  as  a  rule,  in  extensive  burns  of  the  skin  is  due 
to, the  abnormally  increased  radiation  of  heat  from  the  dilated  ves- 
sels in  the  affected  parts  which  have  been  robbed  of  their  protecting 
epidermic  covering.  In  a  number  of  cases  of  burns  very  pronounced 
excitement  is  present  until  shortly  before  death,  while  other  patients 
lie  quietly  in  a  state  of  apathy.  There  is  often  vomiting  and  great 
thirst.  The  urine,  in  the  majority  of  instances,  is  very  scanty,  and 
occasionally  there  may  be  more  or  less  complete  anuria,  and  not  infre- 
quently hsemoglobinuria.  The  latter  is  a  result  of  the  destruction  of 
the  red  blood-corpuscles  which  were  in  the  vessels  of  the  affected  part 
at  the  time  of  the  burning.  If  the  patient  survives  the  first  two  days 
much  has  been  gained,  but  after  the  lapse  of  five  to  six  days,  in  the 
stage  of  the  inflammatory  reaction,  the  above-described  group  of  symp- 
toms may  suddenly  make  their  appearance  and  cause  death  within  a 
few  hours.  In  the  later  stages  the  cause  of  death  is  due  essentially,  as 
we  have  said,  to  the  increasing  exhaustion  ;  a  violent  diarrhoea  begins, 


502    I^'JURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT  PARTS. 

with  now  and  then  the  formation  of  ulcers  in  the  duodenum,  usually  in 
the  neighbourhood  of  the  pylorus. 

Causes  of  Death  after  Extensive  Burns. — How  is  the  death  which  quickly 
ensues  after  extensive  burns  to  be  explained  '{  The  opinions  of  various  au- 
tliorities  dilfer  greatly  upon  tliis  subject,  and  as  yet  no  generally  satisfactory 
exjilanation  has  been  advanced.  According  to  Wertheim,  Ponfick,  and 
others,  the  above-mentioned  destruction  of  the  red  blood-corpuscles  is  the 
main  cause  of  death.  Tlie  marked  diminution  in  tlie  number  of  i-ed  blood- 
corpuscles  which  are  necessary  for  respiration  and  for  metabolism,  produces, 
according  to  this  view,  death,  with  symptoms  similar  to  those  in  carbonic- 
acid-gas  poisoning.  Furthermore,  the  plasma  is  diminished,  and  this  causes 
a  thickening  of  the  blood,  which  may,  however,  be  compensated  for  on  the 
second  or  third  day  afterwards  (Tappeiner,  Koch).  In  addition,  the  sudden 
destruction  of  the  red  corpuscles  has  in  itself  a  deleterious  effect.  In  conse- 
quence of  the  destruction  of  the  red  cells,  the  hcemoglobin  is  dissolved  in  the 
blood,  and  this,  as  we  know,  is  also  a  means  of  rapidly  destroying  the  white 
blood-corpuscles,  and  of  favouring  the  development  of  the  fibrin  ferment, 
and  of  extensive  coagula  in  the  vessels.  As  a  matter  of  fact,  extensive 
thrombi,  originating  int)'a  vitam,  are  found  in  the  vessels  of  all  the  different 
organs  ;  this  has  been  recently  demonstrated  in  man  and  animals  by  Silber- 
mann  and  Welti.  Furthermore,  larger  or  smaller  amounts  of  ha3moglobin 
are  frequentlj'  found  in  the  kidneys,  it  being  most  plentiful  in  the  straight 
uriniferous  tubules,  though  occurring  also  in  the  convoluted  tubules  and 
Avithin  Bowman's  capsule.  From  the  presence  of  haemoglobin  such  kidneys 
have  a  dark,  bi-ownish-red  colour,  which  used  to  be  erroneously  ascribed  to 
excessive  liypera^mia.  In  addition,  the  kidneys  are  more  or  less  hyperasmic, 
and,  like  the  stomach  and  liver,  full  of  necrotic  foci.  These  necroses  become 
more  extensive  with  the  prolongation  of  life  after  the  reception  of  the  burn 
(Welti).  The  diminished  excretion  of  urine  is  explained  by  the  changes  in 
the  kidneys. 

According  to  Salvioli,  the  cause  of  death  from  burns  is  to  be  sought  for 
mainly  in  the  formation  of  numerous  thrombi  and  emboli  made  up  of  blood- 
plaques.  In  consequence  of  these  blood-plaque  thrombi,  and  in  consequence 
of  the  increased  adhesiveness  of  the  blood-corpuscles,  the  circulation  finally 
comes  to  a  comjilete  stand-still.  After  animals  have  been,  as  far  as  possible, 
deprived  of  the  blood-plaqi;es  by  venesection  and  injection  of  defibrinated 
blood,  they  endure  severe  burns  much  better,  for  the  reason  that  the  above- 
mentioned  thrombi  do  not  develop. 

According  to  Sonnenburg.  tlie  prompth'  fatal  cases  of  extensive  burns  die 
of  heart  paralysis.  The  burning  acts  as  an  excessive  irritation  to  the  nervous 
system,  causing  a  reflex  diminution  of  the  vascular  tone. 

Others  lool^;  for  the  cause  of  death  in  the  arrest  of  the  activity  of  the  skin 
and  in  the  formation  of  different  poisonous  substances.  As  a  matter  of  fact, 
severe  burns  often  run  a  course  similar  to  intoxications,  and  it  is  hence  very 
natural  to  seek  for  the  cause  of  death  in  noxious  chemical  products. 

Catiano  has  raised  the  question  whether,  in  extensive  burns,  a  substance 
found  mostly  in  the  skin  is  not  changed,  by  being  rapidly  heated,  into  a 
poison,  the  absorption  of  which  gives  rise  to  the  disturbances  in  question. 


§  90.]  BURNS.  503 

The  sweat  of  the  skin  has  an  acid  reaction  from  formic  acid  (CH2O2).  If 
this  is  gradually  neutralised  on  the  skin  by  ammonium  hydroxide  there 
forms  the  very  easily  soluble  formate  of  ammonium.  If  this  salt  is  rapidly 
heated  it  loses  water  and  changes  into  hydrocyanic  acid.  The  symptoms  of 
hydrocyanic-acid  poisoning  are  said  to  be  in  every  respect  similar  to  those 
following  burns.  According  to  other  authorities,  death  is  caused  by  the 
accumulation  of  ammonia  in  the  blood.  Accoi'ding  to  Reiss,  the  poison 
formed  in  burns  belongs  probably  to  the  pyridin  bases.  The  poison  is 
excreted  by  the  kidneys.  If  one  half  to  one  cubic  centimetre  of  urine  from 
burned  mice  is  injected  into  healthy  mice,  the  latter  die  in  a  few  hours  with 
the  symptoms  of  coma  and  clonic  spasms.  The  alcoholic  extract  of  the  urine 
is  particularly  poisonous. 

According  to  Lustgarten,  Boyer,  and  others,  death  is  due  to  ptomaine 
poisoning.  The  intoxication  is  caused  by  the  metabolic  products  of  the 
bacteria  which,  lying  in  the  depths  of  the  cutaneous  follicles,  have  escaped 
the  effects  of  the  burn.  It  is  true  that  the  degenerations  of  the  kidney, 
lungs,  brain,  "etc.,  which  are  often  present  in  extensive  burns,  point  to  the 
action  of  toxic  substances.  In  any  case,  these  parenchymatous  degenera- 
tions of  the  internal  organs  probably  play  an  important  part  in  the  fatal 
outcome  of  burns. 

The  causes  of  death  in  the  later  stages  of  the  inflammatory  reaction,  as 
well  as  during  the  period  of  suppuration  and  exhaustion,  vary  greatly  in 
their  nature.  The  intensity  of  the  burn  and  the  subsequent  suppuration,  the 
fever,  and  the  individual  peculiarities  of  the  injured  person  are  here  the  most 
important  factors.  Not  infrequently  death  has  occurred  from  pyeemia  and 
sepsis,  particularly  before  the  introduction  of  asepsis.  Among  the  iiafiam- 
mations  of  the  internal  organs  the  most  frequently  observed  are  inflamma- 
tions of  the  intestines,  the  kidneys,  the  lungs,  the  pleuras,  and  the  meninges ; 
they  are  rarely  caused  by  the  action  of  the  heat  during  the  reception  of  the 
burn,  but  are  much  more  frequently  a  result  of  the  gradual  alteration  in  the 
blood  that  occurs  after  the  burn. 

Duodenitis  after  Burns.— The  origin  of  the  duodenal  tdceration  after 
burns,  mentioned  on  page  501,  has  not  as  yet  been  clearly  explained.  Catiano 
believes  that  the  duodenal  ulcers  and  the  intestinal  catarrh  originate  from  the 
destruction  of  the  epithelial  layer  and  the  action  of  the  intestinal  secretion 
upon  the  exposed  parts.  The  epithelial  destruction  is  said  to  be  produced  by 
formate  of  ammonium,  or  by  the  hydrocyanic  acid  that  is  formed  from  the 
latter.  Hunter  also  is  of  the  opinion,  reasoning  from  his  experiments  upon 
dogs  with  toluylendiamin,  that  analogously  to  the  way  this  substance  acts, 
certain  similar  products  of  decomposition  in  the  tissues  are  produced  in  cases 
of  burns  which  are  excreted  in  the  bile  and  are  capable  of  exciting  inflam- 
mation and  ulceration  in  the  duodenal  mucous  membrane. 

Since  the  time  that  we  have  been  able,  with  the  help  of  the  modern  method 
of  treating  wounds,  to  control  suppuration  and  its  accompanying  fever  and 
prostration,  as  well  as  the  accidental-wound  diseases,  cases  of  death  from  sup- 
puration and  other  wound  infections  after  burns  have  become  less  common. 

Prognosis  of  Burns. — The  prognosis  of  burns  may  be  inferred  from 
what  has  been  said.     The  more  extensive  a  burn  is,  so  much  the  more 


504    INJURIES  AND   SURGICAL   DISEASES  OP   THE  SOFT   PARTS. 

unfavourable  is  the  prognosis,  quoad  vitarn.  In  addition,  the  location 
of  the  burn,  as  well  as  the  age  and  constitution  of  the  patient,  plaj  an 
important  part.  Quoad  functionem,  burns  of  the  third  degree,  involv- 
ing the  entire  thickness  of  the  cutis,  are  alone  to  be  feared,  on  account 
of  the  cicatricial  contractures  which  may  result.  Contractures  of  the 
joints,  abnormal  adhesions,  such  as  adhesion  of  the  chin  to  the  neck, 
adhesions  between  the  two  jaws,  contractures  of  the  eyelids,  etc.,  result 
in  this  way. 

Treatment  of  Burns. — Leaving  for  the  present  the  treatment  of  ex- 
tensive bui-ns  endangering  life  out  of  consideration,  the  local  treatment 
of  burns  of  the  first  degree  is  mainly  directed  towards  the  alleviation 
of  the  pain.  This  is  best  accomplished  by  the  local  use  of  cold  in  the 
form  of  ice-bags  and  ice  compresses ;  by  the  use  of  liquor  plumbi  sub- 
acetatis  dilutus  with  ice ;  by  cold  baths ;  by  painting  with  flexible  col- 
lodium,  unguentum  cerussse  or  unguentum  lithargyri  Hebrse  (unguen- 
tum  diachylon)  after  dusting  on  starch,  or  starch  with  oxide  of  zinc, 
dermatol,  etc.,  with  or  without  an  occlusive  dressing  of  cotton  wool. 
Protective  dressings,  according  to  my  own  experience,  are  tlie  best  for 
alleviating  the  pain.  By  placing  the  parts  in  a  proper  position — if  an 
extremity,  by  elevating  it — the  analgesic  effects  of  the  above  remedies 
are  materially  promoted.  In  some  instances  it  is  advisable  to  give  sub- 
cutaneous injections  of  morphine.  In  burns  of  the  second  degree,  when 
blebs  are  present,  it  is  advantageous  to  evacuate  the  blebs  through 
punctures,  but  not  to  remove  the  elevated  epidermis,  to  cleanse  the 
burned  area  in  the  usual  way  with  antiseptic  solutions  (1  to  1,000  bi- 
chloride, or  tliree-per-cent.  carbolic-acid  solutions),  and  then  to  apply  an 
antiseptic  powder  dressing — for  example,  zinc  oxide,  bismuth,  iodoform, 
boric  acid,  aristol,  dermatol,  etc.  As  materials  for  dressings,  it  is  a 
good  plan  to  use  iodoform  gauze  or  sterilised  mull  covered  with  cot- 
ton, or  some  other  aseptic  material,  which  allows  drying  to  take  place. 
These  antiseptic  or  aseptic  dry  powder  dressings  I  consider  far  better 
for  burns  than  the  other  kinds  of  dressings  with  salves  (unguentum 
simpl.,ceruss8e,  diachylon,  vaseline,  etc.),  or  washes  (lime-water  and  lin- 
seed oil,  equal  parts),  or  solutions  of  nitrate  of  silver  (arg.  nitr.,  1  to  100 
of  water).  The  dressing  dries  into  a  firm  aseptic  scab,  which  can  be 
left  uncovered  by  bandages  until  it  falls  off  of  its  own  accord  from  the 
healed  wound.  In  mild  burns  the  formation  of  simple  aseptic  scabs, 
by  means  of  iodoform,  dermatol,  bismuth,  or  zinc  oxide,  without  any 
other  dressing,  is  a  very  excellent  treatment.  After  careful  disinfec- 
tion of  the  bum,  Xitzsche  recommends  covering  it  with  linseed  oil  var- 
nish (1  part  oxide  of  lead  dissolved  in  25  parts  of  boiled  linseed  oil,  to 
which  is  then  added  five  to  ten  per  cent,  of  salicylic  acid  while  the  oil 


§  90.]  BURNS.  505 

is  hot)  ;  over  this  a  layer  of  cotton  is  placed,  and  pressed  down  as  firm- 
ly as  possible  by  an  elastic  bandage.  Healing  generally  follows  under 
a  single  dressing.  The  antiseptic  powder  dressings  are  particularly 
good  for  burns  of  the  third  degree.  In  this  way  the  decomposition  of 
the  burned  tissues  is  most  easily  prevented,  and  the  secretion  or  sup- 
puration is  kept  as  small  as  possible.  The  treatment  of  burns,  like  any 
other  wound,  should  always  be  conducted  with  the  strictest  attention  to 
antiseptic  rules,  and  the  less  often  the  dressings  are  changed  the  better. 
A.  Bidder  recommends  painting  the  burned  area  with  thiolum  liqui- 
dum  or  powdering  it  with  thiolum  siccum,  one  of  the  remedies  belong- 
ing to  the  unsaturated  sulphur  compounds  of  the  hydrocarbons.  In 
extensive  burns  the  patient  should  be  placed,  when  feasible,  in  o. per- 
manent warm  bath  (see  page  182).  The  employment  of  warm  water 
baths  seems  to  me,  however,  dangerous  in  the  first  days  following  a 
burn,  because  they  lower  the  vascular  tone,  and  can  in  this  way  cause 
serious  collapse  and  even  fatal  paralysis  of  the  heart.  The  covering  of 
large  granulating  surfaces  with  skin  can  be  hastened  by  the  transplan- 
tation of  Thiersch  skin  grafts  (§  42),  or  by  the  transplantation  of  large, 
fresh  skin  flaps  with  pedicles  (§  41).  This  is  the  best  way  of  prevent- 
ing the  development  of  cicatricial  contractures  or  abnormal  adhesions. 
If  cicatricial  contractures  or  disfiguring  strips  of  scar  tissue  have  devel- 
oped after  a  burn,  the  cicatrix  should  be  excised  and  the  defect  closed 
by  skin  flaps  with  pedicles  or  Thiersch  skin  grafts.  In  the  milder 
cases  of  contractures  following  burns  systematic  movements  and  mas- 
sage are  sufficient.  The  indications  for  the  amputation  of  extremities 
which  have  been  extensively  burned  are,  in  general,  the  same  as  for 
crushings  and  severe  contusions  of  an  extremity.  The  amputation 
should  be  performed  as  early  as  possible  after  the  first  symptoms  of 
shock  have  subsided. 

In  very  extensive  burns  involving  a  large  portion  of  the  body  the 
treatment  of  the  general  condition  of  the  patient  is  the  first  thing  to  be 
considered.  For  the  collapse  which  occurs  in  conjunction  with  the 
burn,  the  patient  should  be  placed  on  his  back,  wrapped  up  as  warmly 
as  possible,  and  stimulants  (wine,  whiskey,  grog,  black  coffee,  or  any 
warm  stimulating  drink)  should  be  administered.  The  subcutaneous 
injection  of  ether  or  camphor  is  also  advantageous,  as  is  the  temporary 
envelopment  of  the  extremities  in  elastic  bandages  to  drive  more  blood 
to  the  heart  (autotransfusion).  Eestless  patients  should  be  given  mor- 
phine subcutaneously.  Blood-letting,  which  used  to  be  frequently  prac- 
tised, or  blood  transfusion,  should  be  condemned.  On  the  other  hand, 
subcutaneous  salt  infusion  (see  pages  494,  495)  in  proper  cases  of  anae- 
mia or  of  collapse  is  to  be  highly  recommended. 


506    INJURIES  AND  SURGICAL   DISEASES   OF   THE   SOFT   PARTS. 

Burns  from  Lightning. — Li2:htning  produces  the  effect  of  an  elec- 
trical shock  aud  has  a  tearing  and  burning  action.  Sometimes  the  one 
and  sometimes  the  other  of  these  effects  is  the  more  prominent.  If 
people  and  animals  are  directly  struck  by  lightning,  death  occurs 
immediately  in  many  cases,  probably  as  a  result  of  the  violent  elec- 
trical shock  to  the  nerve  centres,  especially  those  governing  respiration 
and  circulation.  The  autopsy  shows  changes  similar  to  those  in  death 
from  asphyxia.  There  is  usually  a  rapidly  appearing  and  marked 
rigor  mortis  (Offenberg).  According  to  Diirek,  the  anatomical  changes 
brought  about  by  hghtning  or  a  strong  electric  current  are  as  follows : 

1,  a  constant  retardation  or  cessation  of  the  coagulability  of  the  blood ; 

2,  usually  circumscribed  or  diffuse  ruptures  of  vessels  along  the  course 
of  the  electric  current ;  3,  sometimes  a  laceration  of  certain  organs ; 
4,  usually  burns  at  the  points  of  entrance  and  exit  of  the  electric  cur- 
rent. The  effects  of  lightning  upon  the  skin  are  manifested  by  all 
sorts  of  changes,  varying  from  a  simple  drying  of  the  epidermis  to  the 
severest  burns.  The  so-called  lightning-marks  upon  the  skin  are  well 
known.  They  consist  of  branching,  brownish-red  zigzag  lines,  the 
formation  of  which  is  probably  connected  with  the  action  of  the  light- 
ning upon  the  blood.  The  colouring  matter  is  set  free  from  the  red 
blood -corpuscles  by  the  electrical  action  of  the  lightning,  and  in  tran- 
suding through  the  walls  of  the  capillaries  or  vessels  forms  marks 
which  correspond  to  the  distribution  of  the  affected  vessels  (Rollet). 
Haberda  exj)lains  the  lightning- marks  by  a  paralysis  of  the  cutaneous 
vessels  resulting  from  the  electrical  action  of  the  lightning  upon  the 
nerves  of  the  vessels.  If  the  person  who  has  been  struck  by  lightning 
lives,  the  symptoms  vary.  The  condition  of  a  person  struck  by  hght- 
ning is  often  precisely  the  same  as  in  concussion  of  the  brain.  Paraly- 
ses, dysphagia,  disturbances  of  sight,  and  other  nervous  phenomena  are 
also  observed.  Lightning  paralyses  have  in  general  a  favourable  prog- 
nosis. The  true  or  direct  paralyses  are  to  be  distinguished  from  those 
occurring  indirectly  from  haemorrhage.  In  the  true  lightning  paraly- 
sis two  stages  can  be  recognised  :  in  the  first  we  have  to  deal  with  a 
direct  injury  to  the  muscles  and  nerves  caused  by  the  lightning,  while 
in  the  second  we  have  the  picture  of  a  traumatic  neurosis  (see  page  285). 
Occasionally  large  vessels  are  ruptured,  followed  by  death,  and  now  and 
then  extremities  are  completely  severed  from  the  body.  From  a  med- 
ico-legal point  of  view  it  is  of  importance  that  the  copper  coins,  for 
example,  in  the  pocket  of  a  person  struck  by  lightning,  can  be  fused 
into  a  single  mass  (Kratter). 

Occurrence  of  Lightning  Strokes  in  Man.  — Sonnenburg  states  that  in  Prus- 
sia, from  185-i  to  1857,  according  to  the  official  statistics,  five  hundi'ed  and 


§90.]  BURNS.  507 

eleven  individuals  v^ere  struck  by  lightning-,  and  72.25  per  cent,  of  the  cases 
were  fatal.  The  great  majority  of  the  individuals  affected  were  struck  while 
at  work  in  the  fields.  The  statistics  of  Boudin  show  that  in  France,  from 
1835  to  1864,  2,324  people  were  struck  by  lightning.  During  the  American 
civil  war,  in  the  summer  of  1864,  the  lightning  struck  among  the  Eighteenth 
Missouri  Regiment,  which  was  encamped  on  a  hill,  and  knocked  down  an  en- 
tire troop.  Almost  all  the  horses  and  eighteen  men  were  killed,  and  all  the 
rest  were  more  or  less  injured.  When  a  row  of  men  or  animals  is  struck 
by  lightning  the  first  and  last  in  the  row  appear  to  be  the  most  endangered. 
It  is  noticeable,  as  Sonnenburg  has  correctly  remarked,  that  bodies  of  troops 
on  the  march  have  only  seldom  been  struck  by  lightning. 

Treatment. — Tlie  treatment  of  lightning  strokes.  })articularly  of  the 
constitutional  symptoms,  is  purely  symptomatic.  Resuscitatory  meas- 
ures often  have  to  be  resorted  to  in  the  form  of  rubbing  the  patient, 
artificial  respiration,  etc.,  and  these  are  sometimes  follovc^ed  by  success 
only  after  a  comparatively  long  time.  The  treatment  of  the  burns  is 
just  the  same  as  described  above.  If  any  paralyses  are  left  they  usu- 
ally disappear  entirely  under  electrical  treatment. 

Sun-burns. — In  consequence  of  the  action  of  the  sun's  rays  upon  the  un- 
covered skin  superficial  burns  are  produced.  These  occur  in  summer  time 
especially  in  tourists  and  mountaineers.  The  skin  becomes  red  and  swollen, 
feels  hot,  and  is  more  or  less  painful  {erythema  solare).  After  a  few  days 
the  burned  layer  of  epidermis  comes  off  in  shreds  from  the  underlying  parts. 
Other  cases  present  a  more  eczematous  appearance,  with  the  formation  of 
blebs  {eczema  solare).  For  prophylaxis  against  sun-burns,  sun-shades  should 
be  carried  or  veils  worn,  etc.  People  with  irritable  skins  when  going  on 
mountain  tours  should  cover  the  exposed  parts  of  their  bodies  with  vaseline, 
or  ungt.  litharg.  Hebrae,  or  with  starch  powder.  The  burns  themselves,  as 
long  as  severe  pain  exists,  should  be  treated  with  applications  of  liq.  plumbi 
subacetatis  dil.  and  ice,  or  with  ungt.  litharg.  Hebrse  or  vaseline,  and  then 
powdered  with  zinc  oxide  and  starch  (1  to  5  to  10). 

Sun-stroke  or  Heat-stroke.— We  have  yet  to  consider  the  so-called 
sun-stroke  or  heat-stroke  {insolation).  This  is  essentially  an  overheat- 
ing of  the  body,  and  often  terminates  very  quickly  in  death,  particu- 
larly in  hot  climates ;  but  the  aifection  is  frequently  seen  in  summer 
even  in  our  latitudes,  especially  among  young  soldiers  who  have  to 
take  long  marches  in  very  hot  weather.  From  the  experiments  of 
Krishaber,  Schleich,  and  others,  we  know  that  the  temperature  of  a 
man's  body,  by  immersion  of  the  latter  in  a  hot  medium,  can  be  made 
to  rise  very  rapidly,  reaching,  for  example,  40°  to  41°  C.  (104°  to 
105.8°  F.)  in  thirty  to  sixty  minutes.  Individuals  thus  treated  become 
restless,  the  respiration  gets  very  frequent,  the  pulse  rises  to  160  or  180, 
the  production  of  urea  is  increased,  etc.  The  marked  rise  in  tempera- 
tare  observed  in  individuals  who  have  been  sun-struck  coincides  with 


508    INJURIES  AND  SURGICAL   DISEASES   OF   THE   SOFT   PARTS. 

these  experiments.  In  a  case  wliicli  terminated  fatally,  Biiumler  found 
the  temperature  of  the  patient  to  be  42.9°  C.  (109.4°  F.)  one  hour  after 
his  reception  into  the  hospital. 

The  symptoms  exhibited  in  sun-stroke  or  heat-stroke  are  very  char- 
acteristic. The  face  is  red,  the  respiration  rapid  and  sighing,  the 
heart's  action  is  very  rapid,  and  the  pupils  are  dilated.  The  patient  is 
unconscious,  delirious,  and  convulsions  often  occur.  Death  takes  place 
in  collapse,  sometimes  very  suddenly.  In  other  cases  the  course  is  not 
so  acute ;  symptoms  of  collapse  are  then  especially  prominent,  from 
which  the  patient  may  recover  entirely.  The  decreased  secretion  of 
sweat  which  is  noticeable  in  insolation  is  important,  especially  as  re- 
gards the  treatment.  At  first  the  secretion  of  sweat  is  very  much 
increased  in  individuals  who  work  or  march  in  very  hot  weather,  or 
with  the  sun  beating  directly  upon  the  head  ;  but  later  it  is  diminished, 
probably  as  a  result  of  the  diminution  of  the  amount  of  water  in  the 
blood,  and  then  the  above-described  symptoms  of  sun-stroke  make  their 
appearance.  As  a  result  of  the  diminution  in  the  production  of  sweat, 
the  loss  of  heat  by  evaporation  becomes  so  much  diminished  that  the 
heat  balance  is  disturbed,  and,  in  consequence  of  the  increased  reten- 
tion of  heat,  the  temperature  of  the  body  rises  moi'e  or  less  i-apidly 
above  the  normal,  even  to  a  fatal  height  (Cohnheim),  The  albuminuria 
as  well  as  the  hsemoglobinuria  sometimes  coming  on  in  horses,  for  ex- 
ample, after  severe  sweating,  are  ascribed  by  Maas  to  the  changes  in 
the  blood,  especially  in  the  serum  albumen  and  the  red  blood-corpus- 
cles, due  to  the  great  loss  of  water. 

The  cause  of  death  in  sun -stroke  or  heat-stroke  is  partly  the  over- 
heating of  the  body  and  partly  the  great  loss  of  water  from  the  body, 
or  the  alteration  in  the  composition  of  the  blood. 

Occurrence  of  Sun-stroke. — Meyer  has  recently  reported  a  great  number 
of  sun-strokes  atfecting  harvest  labourers  almost  like  an  epidemic  in  the  sum- 
mers of  1873  and  1880.  He  ascribes  death  to  cardiac  ^oaraly sis,  due  to  the  in- 
creased temperature  of  the  body  and  to  aii  alteration  in  the  blood  whicli  he 
considers  uriemic.  He  distinguishes  three  stages  of  the  disease  :  a  prodromal 
stage,  a  stage  of  excitement,  and  a  stage  of  depression.  Among  the  numer- 
ous cases,  only  one  terminated  fatally  from  meningitis  and  bilateral  pneu- 
monia. American  physicians  have  also  described  regular  epidemics  of  sun- 
stroke. In  many  campaigns  sun-strokes  have  formed  a  considerable  part  of 
the  diseases  and  deaths.  As  Sonnenburg  mentions,  the  Crusaders  appear  to 
have  suffered  especially  large  losses  by  sun-stroke  and  heat-stroke.  On  the 
march  through  Bithynia  and  Phrygia,  in  July,  1099,  five  hundred  men  often 
perished  on  a  single  day  from  sun-stroke.  During  the  American  war  of 
secession  (1861-'64)  there  were  seventy-two  hundred  sun-strokes,  with  three 
hundred  and  nineteen  deaths.  As  a  result  of  a  forced  mai'ch  during  very 
hot  weather  in  1848,  Sonnenburg  states  that  in  the  Nineteenth  Infantry 


§  91.]  EFFECTS   OF   COLD.  509 

Regiment  of  the  German  army  twenty-nine  men  died.  It  is  a  particularly 
fatal  mistake  to  keep  soldiers,  while  manoeuvring  or  on  the  march,  from 
drinking  water. 

Treatment  of  Sun-stroke. — It  is  my  belief  that  the  treatment  of  sun- 
stroke or  heat-stroke  is  dependent  upon  the  last-mentioned  facts. 
For  prophylactic  reasons,  it  should  be  stated  that  the  withholding  of 
drink  increases  the  danger  of  insolation.  Hence  a  regular  supply  of 
water  to  individuals  while  at  work  or  on  the  march  is  to  be  regarded, 
to  a  certain  extent,  as  a  protection  against  sun-stroke.  When  the 
dreaded  accident  of  sun-stroke  has  occurred,  our  efforts  should  be  di- 
rected towards  lowering  the  temj)erature  of  the  body,  stimulating  the 
secretion  of  sweat,  and  combating  the  weakness  of  the  heart.  We 
try  to  meet  these  indications  by  cold  apphcations  and  cold  baths ;  by 
introducing  large  quantities  of  water  into  the  stomach  and  intestinal 
canal ;  by  the  administration  internally  of  stimulants,  particularly  alco- 
hol ;  by  subcutaneous  injection  of  ether  and  camphor,  and  by  keeping 
the  patient  as  quiet  as  possible.  Many  authorities  have  opposed  the 
energetic  use  of  cold  applications,  cool  baths,  etc.,  and  advocate  warm 
baths  and  warm  rubbing.  I  believe  that  in  sun-strokes  as  vigorous  an 
attempt  as  possible  should  be  made  to  lower  the  temperature  of  the 
body  by  cold  applications,  and,  when  feasible,  by  cool  baths.  Venesec- 
tion should  not  be  employed ;  it  is  useless,  and,  in  fact,  usually  causes 
marked  collapse. 

§  91.  Effects  of  Cold  (Freezing). — There  are  usually  distinguished,  as 
in  burns,  three  different  degrees  in  the  effects  of  cold  upon  the  skin. 
The  first  degree  is  characterised  by  a  superficial,  erythematous  inflam- 
mation, the  second  by  the  formation  of  blebs,  and  the  third  by  eschar 
formation.  The  peripheral  portions  of  the  body — the  toes  and  fin- 
gers, the  feet  and  hands,  the  nose  and  ears— are  especially  exposed  to 
the  danger  of  freezing. 

Symptoms  of  Freezing. — In  cases  of  freezing  there  usually  occurs, 
in  the  first  place,  a  contraction  of  the  cutaneous  vessels,  in  consequence 
of  which  the  affected  skin  area  appears  pale,  and  in  many  individu- 
als corpse-like,  particularly  when  the  fingers  are  involved  ;  this  is  often 
a  result  of  the  action  of  a  very  slight  amount  of  cold.  After  the  first 
•contraction  of  the  vessels  there  follows  a  dilatation  throughout  the 
affected  area ;  the  latter  takes  on  a  deep  red  colour,  and  a  more  or 
less  pronounced  swelling  develops,  which  causes  an  itching  or  burn- 
ing sensation.  Severe  pains  may  also  occur,  especially  when  the  frozen 
parts  are  rapidly  warmed.  In  the  first  degree  of  freezing  this  inflam- 
matory redness  and  swelling  disappear  permanently  within  a  few  days. 
But  not  infrequently  the  frozen  area  of  skin  has  a  tendency  to  become 


510    IXJUKIES  AND  SURGICAL  DISEASES  OF   THE  SOFT  PARTS. 


affected  by  a  constantly  recnrring  redness,  particularly  the  skin  of  the 
nose,  ears,  toes,  and  lingers.  It  may  even  happen  that  such  cutaneous 
areas,  especially  the  point  of  the  nose,  may,  in  consequence  of  a  sort 
of  vascular  paralysis,  remain  red  throughout  life.  The  so-called  chil- 
blains (^perniones)  come  from  a  repeated  slight  freezing  of  the  fingers 
and  toes.  The  extensor  surfaces  especially  become  the  seat,  in  such 
cases,  of  a  dark  or  bluish- red  swelling,  which  has  a  tendency  to  ulcer- 
ate, and  the  patient  is  annoyed  by  severe  itching  and  burning,  jDarticu- 
larly  in  bed,  during  the  change  from  cold  to  thawing  weather,  and  in 
summer.  Individuals  who  have  to  change  constantly  from  cold  to  hot 
atmospheres  are  very  apt  to  suffer  from  chilblains.  Women,  and,  as 
a  general  thing,  anaemic  people,  appear  to  be  most  susceptible  to  these 
mild  degrees  of  freezing. 

In  a  f  rost-l.)ite  of  the  second  degree  the  affected  area  of  skin  assumes 
a  deep  red  or  bluish  colour  and  is  covered  with  blebs.    In  such  cases  it 

is  a  matter  of  great  un- 
certainty as  to  whether 
there  will  finally  occur 
a  complete  restitutio  ad 
integrum,  or  whether  we 
do  not  have  to  deal  with 
a  frost-bite  of  the  thir'd 
degree,  with  its  termina- 
tion in  eschar  formation 
or  in  gangrene.  Speak- 
ing generally,  the  prog- 
nosis of  the  second  de- 
gree of  frost  -  bite  is 
much  more  unfavoura- 
ble than  is  the  case  with 
burns.  Whenever  blebs 
develop  after  a  frost-bite 
there  will  follow  in  the 
majority  of  cases  a  gangrene  of  greater  or  less  depth.  It  is  very 
suspicious,  in  such  cases,  when  the  absence  of  sensibihty  persists  for 
several  days,  and  when  the  area  of  skin — apart  from  the  blebs — appears 
to  be  almost  normal.  In  the  pronounced  cases  of  freezing  of  the  third 
degree  terminating  in  mortification  of  the  affected  tissues  the  parts 
involved  are  usually  entirely  devoid  of  sensation,  of  a  dark  blue  colour, 
and  covered  with  blebs  and  scabs ;  there  is  no  circulation,  as  the  prick 
of  a  needle  draws  no  blood.  The  gangrene  may  be  either  of  the  dry 
or  the  moist  variety,  depending  upon  the  amount  of  evaporation  of  the 


Fig.  362. — Dry  gangrene  from  freezing  :  a,  line  of 
demarcation. 


§91.]  EFFECTS  OF  COLD.  511 

dead  tissue.  I  saw  a  case  of  freezing  involving  both  feet  and  legs,  in 
a  deserter  who  had  wandered  many  days  in  the  forest  during  extreme 
cold  with  insufficient  clothing;  both  legs  were  amputated  and  the 
patient  recovered.  When  extremities  are  entirely  frozen  like  this, 
parts  of  the  toes  can  be  broken  off  through  the  joints  like  glass.  The 
histological  changes  in  freezing  consist  in  a  marked  inflammatory 
reaction  combined  with  different  retrogressive  changes,  and  the  forma- 
tion of  hyaline  and  fibrinous  thrombi  in  the  vessels ;  these  thrombi  are 
probably  the  chief  cause  of  the  gangrene  (Recklinghausen,  Kriegej. 

Eflfect  of  Cold  upon  the  Body. — The  constitutional  effect  of  cold  upon 
the  human  organism  is  a  matter  of  great  interest.  If  an  individual  is 
placed  in  a  cold  medium,  he  will  lose  heat  the  more  rapidly  the  lower 
the  temperature  of  the  medium  and  the  quieter  he  remains.  As  long 
as  a  person  is  in  a  position  to  perform  active  movements  he  can  suc- 
cessfully withstand  severe  degrees  of  cold,  such  as  —  42°  to  —  45°  C. 
(-  4,3°  to  —  49°  F.). 

It  is  not  known  at  what  temperature  man  ceases  to  live.  Tempera- 
tures of  24°  to  26°  C.  (75.2°  to  78.8°  F.)  in  the  rectum  have  been 
repeatedly  recorded  during  the  winter  time  in  drunken  people  who 
afterwards — generally  within  a  few  hours — completely  i-ecovered. 
Cohnheim  believes  that  a  complete  and  rapid  recovery  is  doubtful  when 
the  temperature  in  man  goes  down  to  20°  to  18°  C.  {6S°  to  64.2°  F.). 
The  symptoms  manifested  by  man  correspond  entirely  with  those 
obtained  by  animal  experimentation.  When  a  person  becomes  very 
cold  there  is  a  pronounced  apathy  and  sleepiness,  the  pulse  and  respira- 
tion are  slow,  and  the  pupils  are  widely  dilated  and  react  sluggishly. 
Adolph  Schmidt  found  in  the  blood  of  a  frozen  person  large  numbers 
of  haemoglobin  crystals.  The  haemoglobin  was  in  the  form  of  para- 
haemoglobin,  an  insoluble  modification  of  haemoglobin.  Death  from 
freezing  is  favoured  by  diminished  muscular  movement.  According 
to  Sonnenburg,  thirty-six  per  cent,  of  those  who  are  frozen  are  drunk 
at  the  time. 

Experiments  in  the  Reduction  of  the  Temperature  of  Animals.— Walther, 

Howarth,  and  Cohnheim,  experimenting-  with  animals,  have  studied  the 
consequences  of  cooling  off  the  organism.  If  a  rabbit  or  a  small  dog  is  im- 
mersed to  the  neck  in  water  at  a  temperature  of  about  0°  C,  or  placed  in  a 
small  vessel  surrounded  by  a  cooling  mixture,  in  which  movement  is  impos- 
sible, the  temperature  gradually  sinks.  If  the  animal  is  kept  in  the  cold 
medium  until  the  rectal  temperature  becomes  18°  to  20°  C.  (68°  F.),  as  a  result 
of  this  cooling  ofp  a  general  paralytic  condition  becomes  evident.  The  ani- 
mal is  no  longer  able  to  stand  on  its  legs,  and  lies  as  though  dead,  the  con- 
tractions of  the  heart  are  weak  and  slow  (16  to  20  beats  in  the  minute),  the 
frequency  of  respiration  is  also  diminished,  peristalsis  of  the  intestine  ceases, 


512     INJURIES  AND  SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

and  the  urinary  bladder,  though  filled  to  distention,  is  not  emptied.  The  eyes 
are  widely  opened,  the  cornea  shows  almost  no  reaction,  and  the  pupils  are 
\ery  widely  dilated  and  almost  entirely  insensitive  to  light.  If,  after  the  ani- 
mal has  been  cooled  down  to  a  temperature  of  18°  C.  (64.4°  F.),  he  is  allowed 
to  remain  in  the  cold  medium  still  longer,  death  usually  soon  occurs  in  the 
majority  of  cases  from  cardiac  paralj'sis.  Animals  whose  temperature  has 
been  reduced  to  18'  C.  oi-dinarily  die  when  allowed  to  lie  quietly  at  room 
temperatures ;  but  their  temperature  will  again  rise  to  the  normal  if  they  are 
placed  in  a  hot  medium — for  example,  in  a  vessel  at  a  tempei*ature  of  40°  C. 
(104°  F.).  At  first  the  temperature  rises  very  slowly  to  about  30°  C.  (80°  F.), 
and  then  more  rapidly ;  within  about  two  to  three  hours  the  temperature  of  the 
animal  rises  from  18°  to  39°  C.  (64.4°  to  102°  F.).  The  chilled  animal  can  also 
be  made  to  become  warm  again  by  artificial  respiration.  As  the  temperature 
of  the  body  rises  the  general  paralytic  condition  disappears,  the  activity  of  the 
heart  and  lungs  increases,  intestinal  peristalsis  reappears,  the  urinary  bladder 
is  emptied,  and  finally  the  brain  regains  its  function  and  the  animal  is  again 
full  of  life.  But  many  of  these  animals  die  later  on  after  they  have  re- 
covered their  normal  temperature,  and  occasionally  such  animals  are  even 
subject  to  elevations  of  temperature  with  subsequent  iDronounced  ema- 
ciation. 

According  to  Catiano,  death  from  freezing  is  due  essentially  to  cerebral 
anaemia  wnth  secondary  paralysis  of  the  respiratory  nerves. 

Treatment  of  Freezing. — In  treating  the  mildest  grade  of  frost-bite 
the  affected  part  should  not  be  warmed  too  rapidly,  but  should  be  rubbed 
with  snow  or  ice  water  and  then  wrapped  in  wet  cloths.  A  great 
number  of  remedies  have  been  suggested  for  chilblains.  It  is  always 
important  to  attend  to  the  general  condition  of  individuals  with  a 
tendency  to  chilblains,  and,  as  a  prophylactic  measure,  to  recommend 
warm  coverings  for  the  hands  and  feet  when  the  cold  period  of  the 
year  comes  on.  AYlien  chilblains  are  present  we  try  rubbing  the 
parts  with  snow  and  ice  water,  ice  poultices,  a  foot  bath  of  ice  water 
followed  by  the  application  of  wet  cloths,  painting  the  parts  with  col- 
lodion, traumaticin,  glue,  enveloping  them  wath  strips  of  adhesive 
plaster,  the  application  of  tinct.  iodi.  followed  by  a  warm,  moist  poul- 
tice, mild  caustics,  such  as  dilute  hydrochloric  acid  (1  to  25  or  30  of 
water),  tinct.  cantharid.,  etc.  Vai'ious  kinds  of  salves  have  been  recom- 
mended. Excoriated,  ulcerated  frost-bites  are  best  treated  with  iodo- 
form or  zinc  oxide  and  starch,  or  with  ungt.  litbai'g.  Hebrse  fungt. 
diachylon),  with  or  without  starch,  and  oxide  of  zinc.  Boeck  recom- 
mends for  chilblains,  when  the  skin  is  not  eroded  or  ulcerated,  appli- 
cations with  the  brush  of  ichthyol,  resorcin,  tannin,  aa  1.0,  vtdth  aqua, 
5.0.  This  is  applied  at  night,  and  if  the  skin  is  tender  it  is  covered 
with  mull.  Massage  is  sometimes  useful  in  chilblains.  For  red  noses 
following  frost-bite  I  should  recommend  punctures  made  not  too  deep 
with  the  needle  point  of  the  Paquelin  cautery,  or  the  galvano-cautery, 


§92.]  SUBCUTANEOUS  INJURIES  OF  SOFT  PARTS.  513 

which  causes  the  redness  to  disappear  without  giving  rise  to  a  visi- 
ble scar. 

In  cases  of  extensive  and  deep  freezing  of  the  second  and  third 
degree  involving  an  extremitj,  vertical  suspension  of  the  hmb  should 
be  immediately  employed  to  facilitate  the  restoration  of  the  circulation 
in  the  frozen  parts.  Wet  applications  may  be  combined  with  the  ele- 
vated position  to  stimulate  the  local  vasomotor  ganglia.  If  there  is 
necrosis  of  the  tissues,  antiseptic  dressings  with  iodoform,  or  with  iodo- 
forin  and  charcoal,  naphthaline,  etc.,  or  antiseptic  continuous  irrigation 
should  be  used  as  for  burns.  If  the  frozen  surface  is  very  large  the 
permanent  water  bath  should  be  employed  (see  page  182).  If  gan- 
grene of  an  extremity  develops,  amputation  or  disarticulation  should 
not  be  undertaken  prematurely,  but  antiseptic  treatment  should  be 
kept  up  until  the  line  of  demarcation  has  become  distinct.  Spread- 
ing inflammation  and  suppuration  are  to  be  combated  by  multiple 
incisions,  etc. 

The  treatment  of  freezing  of  the  entire  body  is  as  follows :  In  the 
first  place,  the  person  who  has  been  frozen  must  not  be  warmed  too 
suddenly.  He  should  be  carried  into  an  unheated  room,  rubbed  with 
cold  wet  cloths,  and  then  placed  in  a  bath  at  a  temperature  of  16° 
to  18°  C.  (60.8°  to  64.4°  F.),  which  is  gradually— within  two  to  three 
hours — brought  up  to  30°  C.  (86°  F.).  It  is  often  necessary  and 
always  very  useful  to  perform  artificial  respiration.  Ether  and  cam- 
phor are  given  subcutaneously,  and,  as  soon  as  the  patient  can  swallow, 
alcoholic  stimulants  are  freely  administered.  Wrapping  the  extremi- 
ties in  cold  wet  cloths  is  excellent  for  the  severe  pains  in  the  limbs 
which  occur  as  the  patient  returns  to  life.  Bergmann  and  Keyher  rec- 
ommend suspension  of  the  frozen  extremities  at  the  earliest  possible 
moment,  to  limit  the  gangrene.  There  should  be  no  hesitation  in 
applying  vertical  extension  to  all  four  extremities. 

§  92.  Subcutaneous  Injuries  of  Soft  Parts. — The  most  common  and 
important  subcutaneous  injury  which  the  soft  parts  suffer  is  contusion. 
It  usually  results  from  a  bruising  or  crushing  produced  by  some  blunt 
object,  by  a  thrust,  blow,  or  fall.  The  soft  parts  are  either  squeezed 
together  as  a  whole,  or  pressed  against  a  neighbouring  bone.  The  de- 
gree of  the  crush,  of  course,  varies  all  the  way  from  a  slight  bloody 
discoloration,  a  bloody  suffusion  or  suggilation,  to  a  crushing  of  the 
bones  and  soft  parts  into  a  pulpy  mass.  In  many  individuals,  such  as 
the  so-called  bleeders  (see  page  62),  a  comparatively  large  effusion  of 
blood  not  infrequently  follows  a  trifling  contusion  of  the  tissues.  Fur- 
thermore, spontaneous  subcutaneous  haemorrhages  are  not  uncommon 
in  bleeders. 
36 


514    INJURIES  AND  SURGICAL   DISEASES  OF  THE  SOFT   PARTS. 

The  different  soft  tissues  of  the  body  possess  a  very  unequal  power 
of  resisting  a  contusing  force.  As  Gussenbauer's  experiments  teach, 
and  as  daily  experience  proves,  the  loose  connective  tissue  and  the 
small  vessels  and  capillaries  it  contains  have  the  least  powers  of  resist- 
ance. The  skin,  the  fascia,  the  tendons  and  larger  vessels  exhibit  a 
remarkable  resistance  to  the  effects  of  a  contusing  force.  In  general, 
two  degrees  of  contusion  can  be  distinguished,  the  first  being  the  con- 
tusion with  preservation  of  the  affected  parts,  and  the  second  with  their 
destruction  (mortification,  necrosis). 

Symptoms  of  Contusion. — The  most  important  of  the  symptoms  of  a 
contusion  of  the  subcutaneous  tissues  is  htemort'hage.  In  the  majority 
of  cases  the  extravasated  blood  comes  from  the  capillaries  and  veins, 
the  arteries  possessing  great  powers  of  resistance  to  violence  inflicted 
by  a  blunt  object.  As  a  result  of  the  laceration  of  the  lymph  vessels, 
there  is  also  an  extravasation  of  lymph,  and  it  sometimes  happens 
that  the  extravasation  is  made  up  mostly  of  lymph.  This  lymph  ex- 
tra vasate  may  form  a  fluctuating  tumour,  and  usually  is  made  up  of  a 
citron-yellow  or  a  slightly  reddish-coloured  fluid  having  the  compo- 
sition of  lymph  or  blood  serum.  According  to  Gussenbauer,  these 
lymph  effusions  are  particularly  apt  to  occur  when  the  skin  is  more 
or  less  displaced  by  a  traumatism  from  its  position  in  relation  to  the 
underlying  parts.  This  displacement  causes  a  laceration  of  the  lym- 
phatic vessels  which  permeate  the  subcutaneous  cellular  tissue.  The 
lymph  effusions  are  consequently  usually  located  in  the  subcutaneous 
cellular  tissue.  As  a  general  thing,  the  haemorrhage  in  subcutaneous 
injuries,  even  when  large  vessels  are  ruptured,  is  not  dangerous,  and, 
for  the  most  part,  soon  stops  in  consequence  of  the  rapid  coagulation 
which  usually  follows  contusions.  The  extravasated  blood  is  either 
evenly  distributed  throughout  the  contused  tissues  as  a  hsemorrhagic 
infiltration,  or  it  forms  small,  circumscribed  collections  which  arc 
called  ecchymoses  or  suggilations.  The  larger  collections  of  blood 
are  called  haematomata  ;  suffusions,  on  the  other  hand,  designate  more 
superficial,  large,  'spread-out  collections  of  blood.  The  extravasated 
blood  distributes  itself  through  the  tissues  in  the  direction  of  least 
resistance,  especially  between  the  fasciculi  of  connective  tissue,  1)etween 
the  muscles,  in  the  subcutaneous  cellular  tissue,  etc.  If  the  bleeding 
takes  place  into  a  free  cavity,  a  bursa  or  a  joint,  or  into  one  of  the 
cavities  of  the  body,  a  large  collection  of  blood  may  result.  The  col- 
lections of  blood  in  the  cavities  of  the  body  have  their  special  nomen- 
clature, an  effusion  of  blood  into  a  joint  being  called  hsemarthros;  into 
the  pleura,  hsemothorax  or  hsematctthorax,  etc.  Other  blood  effusions 
have  likewise  received  particular  names,  according  to  the  locality  in 


§92.]  SUBCUTANEOUS  INJURIES   OP  SOFT    PARTS.  515 

which  the}^  occur — for  example,  the  blood  tumour  on  the  head  of  a 
newborn  infant  is  called  a  cephalo-hsematoma ;  a  haemorrhage  into  the 
brain,  an  apoplexj,  etc. 

The  haemorrhages  into  the  large  cavities  of  the  body  are,  of  course, 
dangerous,  and  are  not  infrequently  fatal,  partly  because  of  the  amount 
of  blood  poured  out,  which  has  been  able  to  escape  freely,  and  partly 
because  of  the  pressure  of  the  extravasation  upon  organs  such  as  the 
heart  or  brain,  which  are  necessary  for  the  preservation  of  life.  It  is 
well  known  that  no  less  danger  attaches  to  h^mori-hages  into  the  brain 
itself,  the  so-called  apoplexies  by  which,  apart  from  other  disturbances, 
the  substance  of  the  brain  is  partially  destroyed,  and  rapidly  develop- 
ing paralyses  and  death  are  produced. 

As  the  larger  arteries  are  in  general  deeply  located  in  the  soft  parts, 
and  their  tough,  elastic  walls  are  not  easily  torn,  it  but  rarely  happens 
that  they  suffer  a  subcutaneous  rupture.  But  if  it  does  happen  as  a 
result  of  unusual  violence,  a  pulsating  tumour  may  be  formed — a  so- 
called  traumatic  aneurism  (§  95,  Aneurism).  When  the  extravasated 
blood  comes  from  an  artery  or  from  the  larger  veins  the  hydrostatic 
pressure  in  the  connective-tissue  spaces  usually  soon  rises  to  such  an 
extent  as  to  arrest  the  bleeding,  the  rupture  in  the  ai'tery  being  closed 
by  a  coagulum.  But  the  presence  of  pulsation  in  an  extravasation  of 
blood  does  not  in  all  cases  indicate  a  subcutaneous  injury  to  an  artery. 
The  pulsation  may  be  only  apj)arent,  and  due  to  the  rise  and  fall  of  the 
more  or  less  tense  extravasation  caused  by  the  pulsation  of  the  under- 
lying uninjured  artery.  If  the  apparent  pulsation  of  a  tumour  is  com- 
municated from  an  adjoining  artery,  the  tumour  shows  no  increase  in 
all  dimensions  with  each  systole,  but  only  in  a  direction  at  right  angles 
to  the  underlying  artery.  On  the  other  hand,  an  artery  may  have  re- 
ceived an  injury,  and  yet,  on  account  of  the  thickness  of  the  overlying 
layers  of  tissue,  it  will  be  impossible  to  detect  pulsation. 

The  recognition  of  extravasated  blood  when  the  haemorrhage  is 
superficial  presents  no  difficulties.  The  haemorrhages  into  the  skin 
and  subcutaneous  cellular  tissue  are  usually  seen  immediately.  In 
such  cases  the  skin  has  a  dark-red  or  violet  colour,  and  the  greater  the 
haemorrhage  the  more  extensive  is  the  doughy  and  fluctuating  tumour. 
As  a  result  of  the  distribution  of  the  colouring  matter  of  the  blood  in 
the  tissues  of  the  cutis,  there  occur  within  the  first  few  days  following 
the  injury  various  shades  of  discoloration,  of  which  green,  dark  green, 
and  yellow  usually  predominate ;  they  often  persist  a  week  or  so  as  a 
symptom  of  the  contusion  which  the  skin  has  suffered.  The  larger 
the  swelling  the  greater  is  the  subcutaneous  extravasation  of  blood. 
The  more  deeply  situated  extravasations  in  the  extremities  cannot  be 


516     INJURIES  AND  SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 

recoo'iiised  solely  by  iuspection  ;  it  is  usually  necessary  to  make  use  of 
palpation  of  the  contused  soft  parts.  As  a  general  thing,  crushed  soft 
parts  are  rendered  hard  by  the  bloody  inliltration ;  they  are  thick- 
ened and  give  a  feeling  of  resistance.  In  the  worst  degree  of  contu- 
sions, on  the  other  hand,  such  as  those  in  which  the  soft  parts  and 
the  bones  are  crushed  to  a  pulp  by  the  wheel  of  a  heavy  wagon,  the 
affected  parts  are  changed  into  a  shapeless  mass  devoid  of  circulation, 
with  or  without  preservation  of  the  cutaneous  coverings. 

The  comparatively  rare  extravasations  of  pure  lymph  are  distin- 
guished from  blood  extravasations  by  their  slower  increase  in  volume, 
by  the  absence  of  discoloration  of  the  skin,  and  of  all  the  other  symp- 
toms which  occur  as  a  result  of  the  coagulation  of  blood  and  of  the 
presence  of  the  colouring  matter  of  blood  in  the  tissues. 

Fever  in  Subcutaneous  Injuries. — Following  subcutaneous  injuries  of 
tissue  there  will  sometimes  be  fever,  and  yet  there  will  be  no  symp- 
toms worth  speaking  of  which  indicate  either  inflammation  or  sup- 
puration ;  thus  in  subcutaneous  extravasations  of  blood  or  subcutaneous 
fractures  there  will  sometimes  be  an  elevation  of  temperature  to  101° 
to  102°  F.,  or  even  as  high  as  104°  F.  The  cause  of  this  fever  is  to 
be  ascribed,  in  these  eases,  to  the  taking  up  of  the  products  of  destmc- 
tion  in  the  tissues  by  the  circulating  fluids  of  the  body  (see  §  62,  Fever). 

In  addition  to  the  elements  of  the  blood  and  lymph,  ingredients  of 
the  contused  tissues  are  also  taken  up  into  the  circulation,  especially 
fat,  which  may  enter  the  blood  and  lymph  vessels,  thus  causing  exten- 
sive fat  emboli  in  the  lungs  and  brain.  Fat  emboli  are  particularly 
apt  to  occur  when  the  marrow  of  a  bone  is  injured,  as  in  a  fracture. 
When  we  come  to  the  latter  subject  these  emboli  will  be  discussed 
more  fully. 

Disturbance  of  Function. — The  disturbance  of  function  exhibited  by 
the  contused  soft  parts  varies  greatly  according  to  the  portion  of  the 
body  affected  and  the  degree  of  the  contusion.  A  contused  joint  in 
which  there  is  a  large  intra-articuiar  extravasation  of  blood  naturally 
has  its  mobility  affected.  A  crushed  muscle  which  has  suffered  com- 
plete rupture  will  be  unable  to  contract,  and  the  rupture  of  a  nerve, 
such  as  a  mixed  nerve  in  an  extremity,  will  give  rise  to  a  paralysis  of 
the  muscles  which  it  supplies. 

The  pain  which  is  felt  in  a  contusion  at  the  moment  the  violence 
is  exhibited  varies  greatly  according  to  the  richness  of  the  nerve  supply 
in  the  affected  portion  of  the  body,  and  according  to  the  amount  of 
crushing  sustained  by  the  nerves.  If  from  the  effects  of  the  violence 
a  large  sensory  nerve  is  injured,  the  pain  at  the  moment  the  injury  is 
received  is  very  severe,  and  the  person  who  has  been  injured  feels  the 


§92.]  SUBCUTANEOUS  INJURIES  OF   SOFT   PARTS.  517 

pain  of  the  contusion  not  only  at  the  point  where  the  injury  was  re- 
ceived, but  usually  all  along  the  course  of  the  nerve,  and  so  at  points 
widely  removed  from  the  injury. 

Results  of  the  Contusion  of  a  Nerve. — Concussion  of  the  nerve  sub- 
stance is  particularly  apt  to  occur  in  contusions  of  the  skull.  When  a 
blow  is  received  on  the  head,  the  symptoms  of  concussion  of  the  brain 
{commotio  cerebri)  are  very  plain,  and  eventually  may  be  combined 
with  so-called  focal  symptoms  indicating  an  injurj^  to  some  particular 
part  of  the  brain,  or  with  symptoms  of  compression  from  extravasated 
blood  which  may  collect  between  the  brain  and  the  skull  (see  Regional 
Surgery).  In  other  cases  the  symptoms  of  concussion  of  the  brain 
and  spinal  cord  are  produced  indirectly,  as  by  falls  upon  the  feet.  In 
the  same  way  a  concussion  of  the  nervous  system  or  a  contusion  of 
a  nerve  due  to  an  injury  to  any  part  of  the  body  can  rellexly  affect 
the  central  nervous  system  to  such  a  degree  as  to  give  rise  to  the  set  of 
symptoms  known  as  shock  (see  §  63). 

The  severity  of  the  injury  to  the  skin  is  of  the  greatest  importance 
as  regards  the  subsequent  course  of  the  contusion,  but  the  extent  of 
this  injury  cannot  always  be  determined  from  the  iirst.  The  severity 
of  the  injury  to  the  skin  depends  upon  the  shape  of  the  body  inflicting 
the  contusion  and  the  force  with  which  it  acts,  and  upon  the  elasticity 
and  thickness  of  the  skin,  which  vary  in  different  portions  of  the  body 
and  in  different  individuals. 

If  the  skin  is  contused  to  such  an  extent  that  all  the  vessels  are 
ruptured  and  the  circulation  in  the  affected  area  is  stopped,  the  natural 
consequence  is  death  or  necrosis  of  the  tissues  thus  deprived  of  nutri- 
tion. An  area  of  skin  like  this  contains  no  blood,  and  none  flows 
when  an  incision  is  made  into  it,  and  no  pain  from  the  incision  will  be 
felt  by  the  patient.  Sometimes  an  apparently  dead  portion  of  skin  re- 
covers, the  circulation  becomes  established  here  and  there,  and  then 
the  entire  thickness  or  the  entire  area  of  contused  skin  does  not  per- 
ish. The  subcutaneous  soft  parts  and  the  bones,  like  the  skin,  may 
also  suffer  a  primary  necrosis  in  consequence  of  a  crushing  injury. 
There  is  another  kind  of  death  of  tissue  which  is  secondary  in  its 
nature  and  caused  by  the  inflammation  that  takes  place  after  the 
injury. 

If  the  integrity  of  the  skin  has  been  preserved,  absorption  of  the 
subcutaneous  extravasation  of  blood  usually  takes  place  without  any 
particular  disturbance.  During  the  first  few  days  following  the  injury 
the  contused  skin  exhibits  the  characteristic  changes  which  take  place 
in  the  colouring  matter  of  the  blood.  The  discoloration,  which  at  the 
outset  is  dark  blue  or  bluish  red,  becomes  brownish,  dark  green,  green, 


518    INJURIES  AND  SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 


and  finally  yellow;  the  yellow  stain  often  persists  for  weeks  or  months. 
Occasionally  the  areas  of  discoloured  skin  are  very  extensive. 

Absorption  of  the  Blood  Extravasation.— The  extravasated  blood  is  ab- 
sorbed as  follows :  First  the  tiuid  portion  of  the  coaguluni  is  taken  up  and 
carried  off  by  the  lympliatic  vessels,  and  then  the  fibrinous  portion  becomes 
liquefied  and  is  likewise  absorbed  by  the  lymphatics.  Some  of  the  colourless 
blood-corpuscles  disintegrate  when  coagulation  takes  place,  while  others  are 
forced  out  of  the  clot  as  it  coagulates,  or  leave  it,  according  to  Cohnheim,  by 
spontaneous  locomotion.  The  chief  interest  in  tlie  resorption  of  extravasated 
blood  centres   ui)on   the  fate  of   the  red  blood-corpuscles.     Many  of  them 

get  into  the  lymph  channels  and 
are  carried  by  the  lymph  current  to 
the  nearest  lymphatic  glands,  where 
the}"  occasionally  accumulate  in  such 
**      '^^  '  ^k.^"''^**^©^,^^^  numbers  as  to  cause  marked  swelling 

of  the  glands  and  to  make  a  section 
of  their  parenchyma  pi'esent  an  even- 
ly disti-ibuted   dark-red  a])peai'ance. 


mm^mim&>mmw^^ 


■  --'^,19 


Fig.  363. — Collection  of  blood  in  a  retroperito- 
neal lymph  glund  resultinji  from  a  subcu- 
taneous laceration  and  contusion  of  the 
psoas  muscle  with  fracture  of  the  pelvis. 
X  30. 


Fig.  364. — Collection  of  blood  in  the  liver  after 
subcutaneous  laceration  and  contusion  of 
the  psoas  muscle  with  fracture  of  the  pel- 
vis.    X  80. 


I  found  in  a  case  of  fractured  jDelvis,  with  a  subcutaneous  rupture  and  con- 
tusion of  the  psoas  muscle,  a  very  extensive  collection  of  red  blood-cells  in 
the  retroperitoneal  lymph  glands  (Fig.  363).  Similar  accumulations  of  red 
blood-corpuscles  or  of  blood  pigment  (Fig.  364)  were  also  present  in  other 
organs,  particularly  the  liver.  These  observations  show  that  red  l)lood-cor- 
puscles  are  taken  up  in  great  numbers  by  the  lymph  channels  and  enter  the 
circulation.  Another  portion  of  the  red  corpuscles  disappear  171  loco  by 
granular  degeneration  after  they  have  previously  become  decolouri.sed  by 
loss  of  their  colouring  matter.  The  colouring  matter  of  the  blood  is  diffused 
through  the  surrounding  parts  and  a  portion  of  it  is  simply  absoi^bed,  while 
another  portion  is  changed  into  crystalline  hiematoidin — i.  e..  into  oblique 
rhomboid  crystals  about  0.1  millimetre  long,  of  a  yellowi,sh-red  to  brick-red 
colour.  Together  with  these  crystalline  forms  there  also  occur  orange-yellow 
needles  and  small  angular  or  indentated  rust-coloured  particles.  The  lia?raa- 
toidin  is  not  formed  solely  by  direct  transformation  of  free  red  blood -corpus- 


§93.]  SUBCUTANEOUS  INJURIES   OF   SOFT   PARTS.  519 

cles,  but  also  originates  intracellularly — that  is,  the  red  corpuscles  are  taken 
up  by  the  lymph  corpuscles  and  the  colourless  blood-corpuscles  and  ai'e  here 
changed  into  pigment  (Langhans). 

Other  Terminations  of  Extravasations  of  Blood. — The  most  satisfac- 
tory teraiination  for  an  extravasation  of  blood  is  its  complete  absorp- 
tion in  the  manner  described  above.  "When  the  extravasation  is  dif- 
fuse, absorption  is  the  commonest  termination.  The  particles  of  pig- 
ment and  crystals  of  hsematoidin  gradually  disappear  in  the  course  of 
months,  leaving  nothing  which  recalls  the  hsemorrhage  that  has  oc- 
curred or  the  injury  which  the  tissues  have  suffered. 

Organisation  of  the  Extravasated  Blood. — In  severer  contusions  with 
larger,  more  circumscribed  extravasations  of  blood,  the  extravasation 
is  gradually  displaced  by  new-formed  connective  tissue,  as  in  the  so- 
called  organisation  of  a  thrombus  in  a  vessel  (see  page  296).  In  con- 
tusions of  periosteumj  or  of  bone  or  its  marrow,  the  product  of  the 
organisation  is  not  connective  tissue  but  bone. 

Sometimes  the  oro-anisation  of  the  extravasated  blood  into  connect- 
ive  tissue  is  confined  to  the  outer  layers  of  the  extravasation,  as,  for 
example,  in  cerebral  haemorrhages  or  in  haemorrhages  into  the  sub- 
stance of  the  thyroid  gland  or  of  a  tumour.  In  this  way  there  devel- 
ops at  the  point  where  the  extravasation  occurred  a  cyst — that  is,  a 
space  filled  usually  with  a  yellowish-red  fl.uid  and  enclosed  by  a  con- 
nective-tissue capsule.  After  the  liquid  in  the  cyst  has  been  absorbed 
a  true  connective-tissue  cicatrix  may  eventually  develop. 

Drying,  Calcification,  Suppuration,  and  Decomposition  of  the  Extrava- 
sated Blood. — In  rare  cases  the  extravasated  blood  becomes  dried,  or  cal- 
careous concretions  are  formed  by  deposition  of  lime  salts.  The  unfa- 
vourable changes  which  the  extravasation  may  undergo  are  suppuration, 
and  particularly  putrefactive  decomposition  and  gangrene.  These  ter- 
minations are  only  brought  about,  as  mentioned  in  §  57,  by  bacterial 
infection  through  a  cutaneous  injury,  or,  in  rare  instances,  through  the 
circulation,  and  are  seldom  observed  in  subcutaneous  extravasations  of 
blood.  When  infection  does  occur  it  is  usually  due  to  a  superficial 
cutaneous  injury  or  to  necrosis  of  the  skin  cansed  by  the  injury.  It 
is  also  to  be  borne  in  mind  that  bacteria  may  be  forced  into  the  skin 
when  the  latter  is  subjected  to  violence,  and  they  will  then  find  a 
favourable  medium  for  their  development  in  the  extravasated  blood 
and  the  contused  skin. 

Absorption  of  Extravasated  Lymph. — The  more  or  less  pure  lymph 
extravasations  are  ordinarily  absorbed  very  slowly,  and  they  sometimes 
persist  for  months  as  a  soft  fluctuating  tumour ;  it  is  an  exceedingly 
rare    occurrence    for    them    to    undergo    suppuration  or  ]3utrefactive 


520    INJURIES  AND  SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 

change.  The  repair  of  a  wound  and  the  regeneration  of  injured  tis- 
sues are  described  in  §  61. 

Treatment  of  Contusions. — The  treatment  of  a  contusion  is,  in  the 
first  place,  directed  toward  as  rapid  an  absorption  as  possible  of  the 
extravasation.  A  great  number  of  the  slighter  contusions  get  well 
without  assistance  in  a  comparatively  short  time.  If  a  contusion  of 
soft  parts — on  an  extremity,  for  instance — comes  under  observation 
immediately  after  it  has  been  received,  and  if  a  fracture  has  been  posi- 
tively excluded,  the  injured  extremity  should  be  placed  in  an  elevated 
position  to  diminish  the  pain  and  check  the  subcutaneous  hcemorrhage. 
With  the  same  object  in  view  ice  is  employed  locally,  or  cold  applica- 
tions, to  which  may  also  be  added  substances  like  acetate  of  lead,  chlo- 
ride of  ammonium,  spirits  of  camphor,  etc.  It  is  always  advantageous 
for  arresting  subcutaneous  haemorrhage  to  apply  a  dressing  which  ex- 
erts a  slight  pressure.  If  the  skin  is  intact  and  there  is  a  considerable 
extravasation  of  blood,  the  latter  should  be  mechanically  foi'ced  into 
the  interstices  of  the  tissues  and  into  the  lymph  channels  by  being 
gently  kneaded  and  rubbed  in  a  centripetal  direction  by  the  thumbs, 
fingers,  or  palms.  In  tliis  manner  the  absorption  of  the  extravasation. 
is  hastened.  After  the  massage,  it  is  often  advantageous  to  wrap  the 
injured  portion  of  the  extremity  in  a  flannel,  mull,  or  cotton  bandage 
to  prevent  a  recurrence  of  the  subcutaneous  haemorrhage  and  swelling. 
As  a  general  thing,  it  is  a  good  plan,  immediately  after  the  massage,  to 
make  the  patient  move  his  contused  muscles  or  joint.  This  increases 
the  effect  of  the  massage  and  materially  hastens  the  alDsorption  of  the 
extravasation.  Massage  is  suitable  for  subcutaneous  ruptures  and  con- 
tusions like  sprains  of  joints,  which  can  often  be  cured  by  this  method 
within  a  few  days ;  in  fact,  the  effects  of  massage  upon  a  sprain  often, 
seem  perfectly  wonderful  to  the  laity.  The  patient  may  have  suffered 
the  severest  kind  of  pain  when  making  the  least  attempt  to  stand  upon, 
his  contused  foot  or  ankle,  and  yet  after  massage  has  been  practised 
but  once  he  will  be  able  to  get  about  with  very  slight  pain,  or  even, 
none  at  all. 

The  massage  must  be  repeated  daily,  and  in  the  most  favourable 
cases  three  to  five  sittings  will  be  enough  to  effect  a  cure,  while  in 
others  the  massage  must  be  continued  for  a  longer  time.  The  sooner 
the  massage  can  be  undertaken  after  the  injury  the  more  rapid  will  be 
the  success. 

Teclmique  of  Massage. — The  technique  of  massage  is  not  as  simple  as  it 
appeal's.  It  has  recently  been  employed  with  success  for  all  sorts  of  troubles. 
Before  beginning  the  treatment  upon  the  injured  portion  of  the  body,  it  is 
very  often  advisable  to  start  with  an  introductory  massage  of  the  healthy 


§  93.]  SUBCUTANEOUS  INJURIES  OF   SOFT  PARTS.  521 

parts  on  the  proximal  side  of  the  injury,  using  centripetally  directed  strokes 
of  the  hand  to  empty  the  veins  and  lymphatic  vessels  and  thus  promote*  the 
absorption  from  the  injured  portion  of  the  body.  Massage  of  the  healthy 
parts  on  the  proximal  side  of  the  injury  should  be  employed  in  all  cases 
where  massage  of  the  actually  inflamed  or  injured  portion  of  the  body  is 
impossible  on  account  of  a  cutaneous  injury  or  too  great  pain.  The  parts  to 
be  massaged  and  the  hands  of  the  inasseur  should  first  be  smeared  with  lard 
or  vaseline,  to  facilitate  the  strokes  given  by  the  hand. 

There  are  in  general  four  methods  of  employing  massage  :  1.  Effleurage, 
or  centripetally  directed  strokes  of  varying  strength  made  with  the  palm  of 
the  hand  or  its  radial  border.  2.  Massage  a  friction,  or  vigorous  circular 
rubs  with  the  hand  or  finger  tips,  and  particularly  with  the  thumbs,  to  break 
up  and  scatter  pathological  products.  3.  Petrissage,  or  elevation  of  a  por- 
tion of  tissue  with  both  hands,  or  with  the  fingers  of  one  hand,  followed  by 
squeezing  and  kneading  the  parts  thus  lifted.  4.  Tapotement,  or  beating  and 
striking  the  part  under  treatment  with  the  hand,  or  with  some  instrument 
made  of  wood,  rubber,  etc.,  specially  constructed  for  the  purpose.  The 
length  of  time  occupied  at  each  sitting  varies  greatly  ;  it  may  be  two  to  three 
minutes,  or  as  much  as  five  to  fifteen  minutes  or  longer,  depending  upon  the 
extent  of  surface  to  be  covered.  Attempts  have  been  made  to  substitute  for 
hand  massage  the  use  of  special  apparatus  and  appliances,  particularly  in 
medico-mechanical  institutions.  Massage  with  a  skilful  hand  is,  however, 
the  most  efficacious.  Massage  should  be  performed  much  more  often  by 
physicians,  and  not  by  the  laity,  as  only  the  former  can  feel  properly  and 
diagnosticate  the  pathological  changes  that  are  present. 

Of  course,  a  great  number  of  contusions  are  not  suited  for  massage. 
In  this  category  belong  all  cases  in  which  the  skin  has  been  severely 
damaged  by  mechanical  violence,  or  where  large  vessels  have  been  rup- 
tured, in  consequence  of  which  considerable  extravasations  of  blood 
have  occurred,  or  where,  in  addition  to  an  extensive  contusion  and 
crushing  of  soft  parts,  there  is  also  a  fracture  of  a  bone.  Every  cuta- 
neous abrasion,  no  matter  how  superficial  it  may  be,  must  be  care- 
fully treated  upon  antiseptic  principles.  The  subcutaneous  extravasa- 
tion of  blood  will  also  be  diminished  by  an  antiseptic  dressing  which 
exerts  pi'essure.  In  other  cases  there  may  be  a  scab  of  dried  blood 
which  will  protect  the  cutaneous  injury  from  infection.  If  suppura- 
tion occurs — i.  e.,  if  the  skin  becomes  hot,  red,  and  tender,  and  fluctua- 
tion is  detected — incisions  should  be  made  in  the  most  dependent  parts, 
drainage  inserted,  and  antiseptic  dressings  applied.  Should  putrefac- 
tion of  the  extravasated  blood  set  in — i.  e.,  should  there  be  a  rapid  in- 
crease in  the  size  of  the  inflammatory  tumour,  with  high  fever  and 
chills — ^ vigorous  treatment  must  be  adopted.  Incisions  should  be  made 
as  large  and  numerous  as  possible  in  order  that  the  secretion  from  the 
wound  may  freely  escape.  The  wound  should  then  be  disinfected  with 
a  1  to  1,000  solution  of  bichloride  of  mercury,  or  with  a  three-  to  five- 


522    INJURIES  AND  SURGICAL   DISEASES  OF  THE  SOFT   PARTS. 

per^cent.  solution  of  carbolic  acid,  and  all  gangrenous  slireds  of  tissue 
removed.  Early  amputation  is  sometimes  indicated  when  there  are 
extensive  gangrenous  changes,  but,  as  a  rule,  such  interference  is  very 
rarely  called  for.  When  large  extravasations  of  blood  are  absorbed 
very  slowly,  or  at  best  but  incompletely,  it  is  allowable  to  open  them 
up,  scrape  them  out,  and  drain  the  cavity  thus  formed.  This  applies 
especially  to  the  above-mentioned  purely  lymph  extravasations.  They 
neither  coagulate  nor  become  absorbed,  and  are  rather  more  apt  to 
increase  in  size ;  consequently  the  majority  of  these  cases  should  be 
treated  by  operation.  They  should  be  opened  as  much  as  is  necessary 
by  an  incision  and  scraped  out.  Furthermore,  when  a  large  vessel  is 
ruptured  subcutaneously,  unless  the  haemorrhage  ceases,  the  vessel  must 
eventually  be  sought  for  at  the  point  of  the  injury  and  ligated  on  the 
proximal  and  distal  side  of  the  injured  spot,  and  the  intervening  con- 
tused portion  of  the  vessel  extirpated.  The  special  treatment  for  con- 
tusions of  joints  and  bones  is  described  in  the  paragraphs  upon  tliese 
subjects. 

Muscular  paralyses  following  contusions  of  nerves,  if  the  continuity 
of  tlie  nerve  is  not  interrupted,  usually  disappear  under  electrical  treat- 
ment. If  the  nerve  has  been  completely  divided,  neurorrhaphy  should 
be  performed  in  the  ordinary  way  (see  page  -iS-i). 

Subcutaneous  Rupture  of  Healthy  Muscles  and  Tendons. — The  subcu- 
taneous rupture  of  healthy  muscles  and  tendons  ordinarily  only  occurs 
as  a  result  of  the  action  of  great  force,  such  as  a  violent  muscular  effort 
or  an  excessive  strain  at  the  time  of  the  dislocation  of  a  joint,  or  from 
direct  violence,  such  as  a  blow,  etc.  As  a  result  of  excessive  muscular 
exertion,  as  in  jumping,  there  may  occur  a  rupture  of  the  gastroc- 
nemius or  of  the  tendo  Achillis.  In  a  similar  manner  there  may  fol- 
low a  rupture  of  the  tendon  of  the  quadriceps  extensor  when  an  indi- 
vidual is  in  danger  of  falling  and  tries  to  hold  himself  on  his  feet  by 
vigorously  contracting  the  extensor  muscles  of  the  leg.  The  ruptures 
may  be  partial  or  complete,  and  occur  either  in  the  muscle  or  the 
tendon.  Purely  muscular  ruptures  are  most  common  in  long-bellied 
muscles  possessing  either  a  very  short  tendon  or  none  at  all,  such  as 
the  rectus  abdominis  or  the  sterno-cleido-mastoid.  Not  infrequently 
tendons  are  torn  from  their  points  of  insertion  with  or  without  a  tear- 
ing away  of  bone  substance  (so-called  torn  fractures).  The  tear  takes 
place  where  there  is  the  least  resistance.  If  muscles  and  tendons  en- 
dure the  increased  amount  of  strain,  their  points  of  insertion,  the  bony 
prominences,  may  break  oft*,  and  thus  there  may  result  transverse  frac- 
tures of  the  patella,  or  fractures  of  the  processus  calcanei  posterior,  in 
consequence  of  excessive  strain  from  the  quadriceps  femoris  or  gastroc- 


§92.]  SUBCUTANEOUS  INJURIES  OF  SOFT  PARTS.  523 

nemius  witli  its  tendo  Achillis.  Euptures  of  the  tendons  of  the  fingers, 
with  or  without  avulsion  of  a  portion  of  a  phalanx,  are  of  special  prac- 
tical importance ;  thej  result  most  commonly  from  over-extension  or 
over-flexion  with  torsion  (Brault,  Hagler). 

The  tearing  awaj  of  the  muscles  or  tendons  at  their  points  of  in- 
sertion on  the  bones,  with  or  without  laceration  of  bone  substance,  is 
particularly  apt  to  occur  in  traumatic  dislocations  of  joints  such  as  the 
shoulder  or  hip. 

Yery  rarely  ruptures  of  muscles  or  tendons  are  produced  by  direct 
violence — a  blow  or  a  thrust. 

If  muscles  or  tendons  have  suffered  a  loss  in  their  powers  of  resist- 
ance as  a  result  of  inflammation  or  degenerative  processes,  such  as 
fatty  or  waxy  degeneration  accompanying  constitutional  febrile  dis- 
eases, a  very  moderate  amount  of  mechanical  violence  may  prove  suf- 
ficient to  cause  a  rupture.  These  ruptures  of  diseased  muscles  and 
tendons  are  called  spontaneous^  in  contradistinction  to  the  ruptures  of 
healthy  muscles  and  tendons. 

The  syinytoms  of  subcutaneous  rupture  of  a  tendon  or  muscle — an 
accident  which  is  most  commonly  observed  in  military  practice — consist 
first  of  all  in  the  inability  to  perform  those  movements  of  which  the 
ruptured  muscle  is  ordinarily  capable.  At  the  injured  point  it  is  usu- 
ally evident  that  the  ruptured  ends  of  the  muscles  or  tendons  are  sepa- 
rated by  a  greater  or  less  interval,  and  that  in  this  gap  in  the  tissues 
there  is  a  correspondingly  large  fluctuating  extravasation  of  blood.  If 
the  latter  is  considerable  it  may  render  the  diagnosis  diflicult.  The 
patients  themselves  often  direct  the  attention  of  the  physician  to  the 
nature  of  their  injury  by  positively  stating  that  they  have  plainly  felt 
or  heard  a  rupture  of  the  tissues. 

The  subcutaneous  muscular  and  tendinous  ruptures  usually  heal 
readily  under  proper  treatment,  without  being  followed  by  any  disturb- 
ance whatsoever ;  suppuration  is  scarcely  ever  observed.  Even  when 
no  suitable  treatment  is  adopted,  the  muscular  and  tendinous  stumps 
very  often  heal  together  by  the  formation  of  an  interposed  connective- 
tissue  cicatrix,  such  as  takes  place,  for  example,  after  the  subcutaneous 
division  of  the  tendons  and  muscles  undertaken  for  the  cure  of  club- 
foot or  other  joint  or  muscular  contractures.  The  connective-tissue 
cicatrix  interposed  between  the  muscular  and  tendinous  stumps  is  at 
the  outset  adherent  on  all  sides  to  the  surrounding  parts.  These  ad- 
hesions are  gradually  torn  or  stretched  as  soon  as  the  patient  again 
begins  to  use  his  muscles. 

Even  after  loss  of  muscular  substance  such  as  follows  suppuration, 
the  two  stumps  of  the  muscle  can  become  bound  together  by  a  con- 


524    INJURIES  AND  SURGICAL  DISlfcASES  OF  TUE  SOFT   PARTS. 

nective-tissue  cicatrix,  a  kind  of  in.'^crij}tfo  tendinea,  and  the  muscle 
be  rendered  capable  of  performing  its  function. 

It  sometimes  happens  after  subcutaneous  rupture  of  a  tendon  that, 
in  consequence  of  the  retraction  of  the  central  end  of  the  tendon,  the 
two  stumps  do  not  directly  unite  with  one  another  but  with  the  over- 
lying skin.  Both  tendon  stumps  in  such  cases  then  become  adherent 
to  the  skin,  and  the  latter  may  become  so  mobile  that  it  follows  the 
movements  of  the  tendon,  and  the  latter  performs  its  normal  function. 

After  muscular  ruptures  subsequent  contractures  sometimes  de- 
velop. In  this  class  of  cases  belongs  the  so-called  congenital  form  of 
wry-neck  {caput  obstipum),  which  is  due  generally  to  a  partial  rupture 
of  the  sterno-mastoid  muscle,  usually  the  result  of  operative  interfer- 
ence during  birth.  According  to  Stromeyer  and  Yolkmann,  the  con- 
tracture is  produced  in  part  by  a  cicatricial  shrinkage  of  the  muscular 
substance,  and  in  part  by  the  oblique  position  of  the  head  instinctively 
assumed  from  the  time  of  birth.  According  to  Petersen,  the  sternomas- 
toid  muscle  involved  in  caput  ohstip)um  is  congenitally  shortened.  In 
other  cases  a  contracture  after  muscular  and  tendinous  rupture  is  caused 
by  the  action  of  the  antagonistic  groups.  But  it  is  certain,  as  the  divi- 
sion of  tendons  for  contractures  also  proves,  that  these  so-called  antago- 
nistic muscular  contractures  are  not  by  any  means  so  severe  nor  so 
common  as  was  formerly  believed  to  be  the  case.  We  shall  discuss 
this  question  more  fully  under  the  subject  of  contractures  of  the  hand 
and  foot. 

Treatment  of  Subcutaneous  Muscular  and  Tendinous  Ruptures. — This 
consists  essentially  in  approximating  as  closely  as  possible  the  divided 
and  separated  ends  of  the  muscles  and  tendons,  and  preventing  the  use 
of  the  muscles  or  tendons,  whenever  possible,  by  immobilisation  of  the 
affected  portion  of  the  body.  "Wherever  it  is  feasible,  an  attempt  should 
be  made,  after  division  of  the  skin  under  antiseptic  precautions,  to 
obtain  primary  union  by  sutures  connecting  the  muscular  or  tendinous 
stumps  (see  Tenorrhaphy). 

Muscular  Hernia. — The  protrusion  of  a  portion  of  a  muscle  through  an 
unhealed  rupture  in  its  overlying  fascia  or  sheath  is  called  a  muscular  her- 
nia. In  cases  of  this  description,  during  the  contraction  of  the  affected  mus- 
cle, a  portion  of  its  belly  pushes  itself  through  the  gaping  tear  in  the  fascia 
or  sheath  of  the  muscle  and  forms  an  elastic  fluctuating  tumour  (Fig.  .365). 
Herniae  of  the  straight  abdominal  muscles  and  of  the  muscles  of  the  thigh 
seem  to  be  the  most  common,  occurring  particularly  in  the  soldiers  of  cavalry 
and  artillery  regiments.  As  Baudin  has  recently  demonstrated,  the  affection 
is  not  so  rare  as  was  formerly  believed.  In  the  thigh  the  development  of 
muscular  herniae  after  subcutaneous  rupture  of  the  fascia  is  favoured  by  the 
very  slight  distensibility  of  the  fascia,  by  its  tense  arrangement  on  the  inner 


§92.] 


SUBCCTAKEOUS  INJURIES   OF   SOFT   PARTS. 


525 


I 


Fig.  365. — Muscular  hernia  (adductor 
longus)  resulting  from  a  rupture 
of  the  fascia,  due  to  a  fall  from  a 
horse.     (Eawitz.) 


side  of  the  leg,  and  by  a  frequently  repeated,  exce.ssive   stretching  of  the 
adductors  such  as  occurs  in  riding.     The  observations  of  Baudin  show  that  a 
sudden  rupture  of  the  fascia  does  not  necessarily  occui'.     Much  more  com- 
monly there  is  a  gradual  forcing  asunder 
and  tearing  apart  of  the  fibres  of  the  fascia. 
On  account  of  the  poor  nerve  supply  in  the 
fascia,  a  tear  in  the  latter  is  not  ordinarily 
accompanied  by  pain.     As  regards  the  diag- 
nosis, it  is  characteristic  for  tumours  due  to 
muscular    hernise   to    disappear  or   become 
prominent  as  the  points  of  origin  and  inser- 
tion  of  the   afi^ected  muscle  are   separated 
from  or  approximated  to  one  another. 

If  the  discomfort  caused  by  such  a  mus- 
cular hernia  is  considerable,  an  operation 
should  be  undertaken  for  its  cure.  The  skin 
is  incised,  the  ruptured  fascia  exposed,  and 
the  edges  of  the  rent  freshened  and  drawn 
together  by  catgut  sutures.  After  healing  is 
complete,  an  elastic  dressing  which  exerts 
pressure  in  the  form  of  an  elastic  girdle,  pos- 
sibly with  a  flat  pad,  should  be  worn  for  some  time.  In  mild  cases,  and  when 
patients  are  afraid  of  the  knife,  we  are  forced  to  confine  ourselves  to  a  purely 
palliative  treatment  of  the  affection  by  an  elastic  girdle  with  a  flat  pad. 

Dislocations  of  Muscles  and  Tendons. — Displacements  of  muscles 
and  tendons  after  laceration  of  their  fascise  and  synovial  sheaths  have 
received  the  name  of  dislocations.  In  general  they  are  very  rarely 
observed,  and  mainly  occur  when  the  muscle  or  tendon  in  question  by- 
some  violent  movement  slips  over  a  bony  prominence  where  it  is  held 
fast.  Displacement  of  the  tendons  of  the  peronei  muscles  on  to  the 
outer  surface  of  the  external  malleolus  may  occur  in  severe  sprains 
of  the  ankle  joint.  There  is  a  division  of  opinion  as  to  the  frequency 
with  which  dislocation  of  tBe  biceps  tendon  occurs  from  the  bicipital 
groove  over  the  lesser  tuberosity  of  the  humerus.  According  to  Cow- 
per,  the  dislocation  is  particularly  apt  to  occur  in  forced  elevation  of 
the  arm,  and  the  accident  is  characterised  by  severe  pain  iu  the  region 
of  the  lesser  tuberosity,  and  by  Inability  to  move  the  shoulder  joint. 
Jarjavay,  Pitha,  and  others  doubt  the  occurrence  of  simple  dislocations 
of  the  biceps  tendon  unaccompanied  by  dislocation  or  fractnre  of  the 
upper  end  of  the  humerus. 

The  reposition  of  the  dislocated  tendons — of  the  peronei,  for  ex- 
ample— is  an  easy  matter  in  recent  cases.  To  keep  the  tendons  in 
their  proper  position  after  they  have  been  replaced,  a  suitable  retentive 
dressing  should  be  applied  so  as  to  exert  pressure  upon  the  point 
where  the  dislocation  has  occurred,  while  the  joint  is  made  to  assume  a 


526    INJURIES  AND  SURGICAL  DISEASES   OF   THE  SOFT   P^LRTS. 

suitable  position,  which  in  dislocation  of  the  peronei  consists  in  supinat- 
ing  the  foot.  As  dislocations  of  tendons  are  particularly  apt  to  occur 
when  the  bony  grooves  are  not  deep  enough,  and  as  this  condition  also 
favours  their  recurrence,  it  is  occasionally  advantageous  to  make  use 
of  Albert's  method,  and  deepen  the  groove  subperiosteally  with  a 
gouge  and  then  reunite  the  elevated  periosteum  by  catgut  sutures. 
Maydl  recommends  in  addition  freshening  and  suturing  together  the 
lacerated  edges  of  the  tendon  sheath.  If  there  is  atrophy  of  the  ten- 
don sheath,  a  portion  of  the  periosteum  may  be  turned  over  the  tendon 
and  sutured  to  its  sheath. 

Dislocations  of  Nerves. — These  occur  under  conditions  similar  to  those  de- 
scribed for  dislocations  of  the  tendons  and  muscles.  Dislocation  of  the  ulnar 
nerve  from  its  groove  behind  the  internal  condyle  of  the  humerus  is  a  particu- 
larly familiar  accident.  In  obstinate  cases  the  bony  groove  should  be  deep- 
ened subperiosteally  with  a  gouge,  or  the  nerve  should  be  secured  in  position 
by  suturing  its  sheath  to  the  fascia  or  inner  border  of  the  triceps  tendon  and 
covering  in  the  nerve  by  suturing  the  fascia  over  it  to  the  periosteum  (Stabb). 

Subcutaneous  stretching,  tearing,  or  laceration  of  the  capsules  of 
joints  and  their  ligaments — the  so-called  sprains — will  be  discussed 
under  the  subject  of  Injuries  of  Joints  (§  121). 

§  93.  The  Diseases  of  the  Skin  and  Cellular  Tissue. — ^The  diseases 
of  the  skin  are  very  numerous,  since  it  is  so  much  exposed  to  injurious 
influences  from  without,  and  since  it  bears  such  an  intimate  relation- 
ship to  the  whole  organism.  This  relationship  to  the  rest  of  the  sys- 
tem explains  why  the  skin  presents  secondary  symptomatic  changes  in 
diseased  conditions  of  the  nervous  system,  the  blood,  the  lymphatic 
system,  and  the  internal  organs. 

The  trophoneurotic  cutaneous  affections  are  extremely  interesting. 
We  know  that,  as  a  result  of  long-continued  irritation  of  peripheral 
nerves,  there  may  occur  not  only  degenerative  changes  in  the  periph- 
eral portions  of  these  nerves,  accompanied  by  trophic  disturbances, 
but  that  also  the  peripheral  changes  may  advance  in  the  form  of  an 
ascending  neuritis  to  the  spinal  cord  and  brain.  These  secondary  dis- 
eases of  the  central  nervous  system  may  then  in  turn  give  rise  to 
trophic  disturbances  of  the  skin,  to  inflammation,  gangrene,  ulcers, 
vasomotor  disturbances,  etc.  I  should  also  mention  at  this  place  the 
reflex  angioneuroses,  in  which,  as  a  result  of  various  kinds  of  irritation 
such  as  may  proceed  from  the  sexual  organs,  manifold  polymorphous 
exanthemata  including  wheals,  papular  efflorescences,  erythema  nodo- 
sum, etc.,  may  occur.  Yarious  acute  and  chronic  infectious  diseases 
are  accompanied  by  cutaneous  lesions,  and  the  latter  also  occur  from 
the  internal  or  external  use  of  drua^s. 


§93.]      THE  DISEASES   OP   THE  SKIN  AND   CELLULAR   TISSUE.        527 

We  shall  confine  ourselves  here  to  only  the  most  important  dis- 
eases of  the  skin  in  so  far  as  thej  belong  to  the  province  of  surgery. 

Acute  Inflammations  of  the  Skin. — The  principal  acute  inflammations 
of  the  skin  of  interest  to  the  surgeon  are  erythema,  eczema,  furuncle, 
carbuncle,  and  erysipelas ;  the  latter  is  described  in  §  71 . 

1.  Erythema. — By  erythema  {dermatitis  erytheraatosci)  is  understood 
an  acute  circumscribed  inflammation  mainly  involving  the  papillary 
layer  of  the  skin.  In  consequence  of  the  inflammatory  hypersemia  the 
skin  is  reddened  and  somewhat  swollen.  The  temperature  of  the  af- 
fected area  is  elevated,  and  there  is  usually  a  sharp,  burning  pain.  The 
anatomical  changes  in  erythema  consist  in  a  serous  exudation  into  the 
space  between  the  most  superficial  layer  of  the  cutis  and  the  rete  Mal- 
pighii,  and  in  a  more  or  less  pronounced  infiltration  with  leucocytes. 
The  cells  of  the  rete  Malpighii  are  generally  somewhat  enlarged  and 
swollen.  As  a  result  of  the  exudation,  the  epidermis  is  often  elevated 
in  the  form  of  small  blebs  which  are  filled  with  serum  or  pus.  Ery- 
thema usually  terminates  in  a  complete  restitutio  ad  integrum^  without 
leaving  any  visible  cicatrix.  The  epidermis  comes  off  mostly  in  the 
form  of  scales  or  large  flakes.  If  the  irritation  continues  long  enough, 
small  ulcers  may  occasionally  develop  from  the  blebs,  but  these,  too,  as 
a  rule,  heal  very  rapidly.  The  causes  of  erythema  are  very  varied. 
Ordinarily  the  disease  originates  from  a  local  mechanical,  thermal,  or 
chemical  irritation  ;  it  may  thus  come  from  superficial  burns  or  frost- 
bites, from  continued  irritation  of  the  skin  by  wet  bichloride  or  car- 
bolic dressings,  or  it  may  be  caused  by  sweat,  urine,  or  pus,  particularly 
in  localities  where  areas  of  skin  rub  together,  as  at  the  anus,  the  vulva^ 
in  the  axilla,  or  after  the  ingestion  of  various  kinds  of  food  or  medica- 
ments (quinine),  etc. 

Erythema  Multiforme,  Erythema  Nodosum. — In  endocarditis,  as  a  result 
of  infection  by  micro-organisms,  and  in  all  cases  of  acute  and  chronic  infec- 
tious diseases,  various  forms  of  erythema  sometimes  occur,  particularly 
erythema  multiforme  and  erythema  nodosum.  The  etiology  of  erythema 
multiforme  is  extremely  varied.  In  addition  to  the  toxic  influences  which 
bacteria  exert,  a  very  important  part  is  played  by  alterations  in  the  nervous- 
system,  including  both  the  peripheral  nerves  and  the  central  nervous  system, 
and  by  irritations  of  the  skin  when  the  nervous  system  is  normal.  Accord- 
ing to  During  and  others,  erythema  exudativum  multiforme  and  nodosum 
are  specific  infectious  diseases. 

The  Treatment  of  Erythema  consists  in  great  cleanliness  and  the 
use  of  washings  and  baths.  For  pure  hyperseraia  ice  and  lead-water 
should  be  employed,  and  the  parts  should  be  covered  with  unguentum 
lithargyri  Hebrse  (unguentum  diachylon),  or  vaseline,  and  afterwards 
dusted  with  starch  or  oxide  of  zinc  and  starch  (1  to  5  to  10),  and  then 


528    INJURIES  AND  SURGICAL  DISEASES  OF   THE  SOFT   PARTS. 

covered  with  cotton.  The  latter  treatment  is  particularly  good  when 
blebs  are  present ;  thej  rapidly  disappear  under  the  application  of  des- 
iccating substances  such  as  unguentum  diachylon  or  vaseline,  or  when 
dusted  with  starch  and  zinc  oxide.  But  the  cause  of  the  erythema 
should  always  be  taken  into  account,  especially  if  it  is  a  bacterial  ery- 
thema— i,  e.,  an  erythema  occurring  in  the  course  of  an  infectious 
disease. 

2.  Eczema. — Among  the  inflammations  of  the  skin  in  which  there 
is  a  formation  of  blebs  special  mention  should  be  made  of  eczema, 
which  is  sometimes  acute  and  sometimes  chronic,  and  consists  in  the 
development  of  papules,  vesicles,  and  pustules  which  dry  and  form 
crusts.  The  skin  in  the  neighbourhood  of  the  vesicles  is  usually  more 
or  less  inflamed.  Eczema,  too,  is  particularly  apt  to  be  excited  by  all 
sorts  of  external  irritation,  such  as  wet  antiseptic  dressings  of  bichlo- 
ride, carbolic  acid,  etc.  (For  the  eczema  that  occurs  on  the  hands  of 
surgeons,  see  page  179).  A  large  number  of  very  different  skin  dis-' 
eases  are  included  etiologically  under  the  term  eczema  which  should 
really  be  separated.  An  important  type  of  eczema  is  the  eczema 
seborrhoioum,  iv^  which  there  is  a  formation  of  scales  and  crusts  on 
those  parts  of  the  body  which  are  richly  supplied  with  sebaceous 
glqiitls,  such  as  the  hairy  jDortion  of  the  scalp,  the  edges  of  the  eyelid, 
the  axilla,  etc.  (Unna). 

Treatment  of  Eczema. — The  treatment  of  acute  eczema  consists  in 
removing  the  cause,  such  as  the  wet  dressings,  and  then  in  the  appli- 
cation of  drying  remedies  (fifty  per  cent,  alcohol,  brandy)  or  unguen- 
tum diachylon  or  vaseline,  dusting  with  zinc  oxide  and  starch  and 
covering  with  cotton,  but  without  gutta  percha  over  it,  since  the  drier 
the  eczematous  area  is  kept  the  better.  If  success  is  not  obtained  by 
these  methods,  a  trial  should  be  made  with  zinc  glue  (oxide  of  zinc 
and  gelatine,  each  one  part,  glycerine  and  aq.  destil.,  each  four  parts) 
Unna's  ointment  of  benzoate  of  zinc  spread  on  gauze.  Pick's  sahcylic- 
soap  plaster,  Lassar's  zinc  paste,  etc.  Chronic  eczema  is  treated  in 
essentially  the  same  way.  In  addition  we  use  animal  preparations — 
ichthyol  (internally  and  externally),  liniments  which  are  allowed  to 
dry  on,  etc.  Peck's  bichloride  gelatine,  the  salicylic-soap  plaster, 
Lassar's  sahcylic  paste,  Unna's  salicylic- plaster  mull,  two  to  ten  per  cent, 
of  chrysarobin  or  pyrogaUic  acid  in  vaseline,  are  all  useful  prepara- 
tions. The  Rontgen  rays  have  also  been  used  with  success  in  chronic 
eczema.  Arsenic  should  be  administered  internally,  and  in  children 
oftentimes  cod-liver  oil.  Any  constitutional  dyscrasise,  such  as  gout, 
diabetes,  scrofula,  etc.,  should  receive  special  treatment.  The  diet 
should  be  carefully  regulated. 


93.]      THE   DISEASES  OF   THE   SKIN  AND   CELLULAR  TISSUE.        529 


Other  Skin  Diseases. — According  to  the  dijfferent  forms  and  causes  of 
erythema  and  the  skin  inflammations  in  which  blebs  develop,  many  vari- 
eties of  these  diseases  are  distinguished,  such  as  erythema  exudativum  mul- 
tiforme, erythema  nodosum,  urticaria  tuberosa,  impetigo   (pustules   drying 
and  forming  crusts),  etc.     We  cannot  discuss  at  this  place  other  cutaneous 
affections  like  psoriasis  (development  of  dry,  white  scales),  prurigo  (inflam- 
mation accompanied  by  the  formation  of  papules),  and  the  various  mani- 
festations  of   syphilis.     In  urticaria  there  is   an   eruption  of  red    itching 
wheals   which   are  sometimes    pigmented.     By  miliaria   is   understood  an 
eruption   of    small,  transparent  vesicles;   by   herpes,  vesicles   arranged  in 
_groups — for  instance,  upon  the  lips  (herpes  labialis)  or  prepuce  (herpes  pre- 
putialis),  and  on  the  back  (herpes  zoster).     Herpes  zoster  occurs  along  the 
distribution  of    some    particular    nerve,  and    is    sometimes    present  when 
changes  have  taken  place  in  the  spinal  ganglia 
and  the   Gasserian  ganglion.     The  infectious 
character  of  herpes  zoster   is   becoming  moi^ 
and  more  insisted  upon ;  epidemics  of  this  affec- 
tion have  repeatedly  been  observed  (Pick,  Ka- 
posi).   By  pemphigus  is  understood  a  cutaneous 
eruption   with   the  formation  of   blebs  which 
vary  in  size  from  that  of  a  pea  to  that  of  a 
hen's  or  goose's  egg.     It  has  various  causes  :  it 
occurs,  for  example,  in  the  course  of  infectious 
diseases  (sepsis),  in  injuries  and  inflammations 
of  nerves,  after  the  ingestion  of  certain  drugs, 
etc.     The  views  regarding  the  nature  of  pem- 
phigus are  still  very  divided  ;  some  regard  the 
-different  types  as   one  and  the  same  disease, 
while  others  understand  the  term  pemphigus  to 
include  diseases  of  very  variable  etiology.    Two 
main  varieties  can  be  distinguished  clinically  : 
pemphigus  benignus  and  pemphigus  malignus. 
The  latter  is  characterised  by  early  and  often 
primary  involvement  of  the  mucous  membrane 
and  morphological  variations  in  the  ordinary 
picture  of  pemphigus.     The  prognosis   is   un- 
favourable— death  occurring,  according  to  Ka- 
posi, in  about  one  half  the  cases.    Xeroderma  pigmentosum  (Kaposi)  is  a  rare 
skin  disease  in  which  the  skin  becomes  atrophied,  wrinkled,  and  parchment- 
like ;  furthermore  numerous  pigmented  spots  and  telangiectases  are  present. 
The  skin  is  tense,  so  that  the  eyelids  and  lower  lip  appear  everted  and  the 
fingers  bent.     The  disease  begins  in  earliest  childhood,  its  cause  is  unknown, 
and  it  generally  results  fatally,  usually  after  a  long  duration  and  after  the 
formation  of  malignant  tumours.     Frank  and  Sandfort  observed  in  a  thirty- 
three  year-old  mountaineer  a  peculiar  desquamation  of  the  entire  skin  of  the 
hands  and  feet,  including  the  nails.     It  occurred  at  a  certain  time  every 
year.     The  new  skin  was  as  tender  as  that  of  a  child.     Kerion  celsi  is  a  skin 
disease  caused  by  tinea  tricophytina,  which  attacks  principally  the  scalp. 
The  involved  portion  of  skin — e.  g.,  of  the  size  of  a  silver  dollar — is  swollen, 
37 


Fig.  366. — Keuropathic  oedema  of 
the  right  upper  extremity  in  a 
woman  thirty-two  years  old, 
following  a  fall  upon  the  right 
arm. 


530    INJURIES  AND  SURGICAL  DISEASES  OP  THE  SOFT   PARTS. 

perfoi'ated  like  a  sieve,  and  covered  with  crusts.  Removal  of  the  haix'  and 
the  use  of  antiseptic  solutions  (1: 1,000  bichloride,  absolute  alcohol,  etc.)  usu- 
ally bring  about  a  gradual  cure.  Hydroa  vacciniforme  (summer  erujition) 
is  a  very  rare  recurring  skin  disease  which  occurs  chiefly  in  children  on  the 
face  and  hands,  and  is  caused  by  the  action  of  the  sun.  It  consists  in  the 
formation  of  papules  or  vesicles  up  to  the  size  of  a  bean.  These  dry,  form  a 
scab,  and  a  more  or  less  deep  scar  results.  Myiasis,  a  skin  disease  occurring 
in  animals  and  man,  is  caused  by  the  larva3  of  two  varieties  of  diptera,  the 
muscides  and  the  oestrides.  It  occurs  chiefly  in  Central  America  and  Russia. 
The  above  insects  lay  their  eggs  in  summer  inside  the  nose,  auditory  canal, 
upon  the  skin,  cutaneous  ulcers,  etc.,  of  individuals  who  lie  or  sleep  out  of 
doors.  Their  larvaa,  which  creep  out  in  a  few  hours,  penetrate  farther  into 
the  tissues.  The  myiasis  muscosa  sometimes  give  rise  to  extensive  destruc- 
tion of  the  soft  parts  and  suppuration  of  the  cranial  and  facial  cavities,  and 
may  prove  fatal  from  sepsis  and  exhaustion,  while  myiasis  CBstrosa  is  a  local- 
ised disease  with  a  favourable  prognosis.  I  saw  a  case  of  myiasis  muscosa 
end  fatally  from  meningitis.  Myiasis  of  the  skin  (myiasis  dermatosa)  has  in 
general  a  good  prognosis,  particularly  myiasis  dermatosa  cestrosa,  in  which, 
as  a  rule,  the  larvaj  form  passages  in  the  skin  of  different  lengths,  either 
starting  from  an  ulcer  or  the  intact  skin.  The  treatment  of  myiasis  consists 
naturally  in  removal  of  the  larvae.  In  certain  nervous  states,  such  as  neu- 
rasthenia, hysteria,  and  Graves's  disease,  particularly  when  the  blood  is  in  a 
hydra^mic  condition,  more  or  less  circumscribed  oedema  of  the  skin  some- 
times occui's,  running  either  an  acute  or  chronic  course.  The  cause  is  mainly 
an  angioneurosis  or  trophoneurosis  (Sydenham,  Quincke,  J.  Collins,  and 
others).  In  one  case  of  neuropathic  oedema  of  the  skin  of  the  upper  extrem- 
ity following  traumatism  Socin  and  Bircher  obtained  a  cure  by  stretching 
the  brachial  plexus  in  the  axilla.  Certain  drugs  give  rise  to  different  skin 
lesions  in  predisposed  individuals — e.  g.,  antipyrine,  quinine,  potassium  iodide, 
salicylic  acid,  etc.  Caspary  observed  marked  pemphigus  after  the  adminis- 
ti'ation  of  antipyrine.  The  administration  of  quinine  is  followed  by  different 
exanthemata  (erythema,  eczema,  purpura,  pemphigus,  etc.). 

All  moist  cutaneous  affections  ttccorapanied  by  the  formation  of 
blebs  are  best  treated  in  the  manner  described  above  for  eczema — viz., 
by  desiccating  dressin^^s  of  oxide  of  zinc,  with  or  without  previous  or 
simultaneous  ointment  dressings,  such  as  unguentum  diachylon,  by 
dilate  alcohol,  etc. 

3.  The  Furuncle. — By  a  furuncle  is  understood  an  acute  inflamma- 
tion of  the  sebaceous  glands  and  hair  follicles,  which  is  always  due  to 
micro-organisms,  especially  the  Staphylococcus  pyogenes  aureus  and 
alhus.  By  the  penetration  of  the  micro-organisms  into  the  mouths  of 
the  sebaceous  glands  there  is  first  developed  a  pustule  (acne)  about  the 
size  of  a  pin-head,  which  soon  enlarges  into  a  very  painful  nodule  the 
size  of  a  pea  or  bean.  After  a  few  days  suppurative  softening  usually 
develops  in  the  centre  of  the  nodule.  Occasionally  the  inflammation 
extends  more  deeply  and  spreads  into  the  surrounding  parts,  giving 


§93.]      THE   DISEASES   OF   THE  SKIN   AND   CELLULAR  TISSUE.        531 

rise  to  a  cellulitis  with  extensive  suppuration  or  necrosis  of  the  under- 
lying fascia.  Some  people  are  very  subject  to  furuncles.  They  some- 
times develop  simultaneously  in  various  parts  of  the  body  in  indi- 
viduals who  are  otherwise  perfectly  healthy ;  the  same  thing  also 
happens  in  diabetes,  during  the  convalescence  from  typhoid  fever,  etc. 
It  is  interesting  to  note  that  during  the  furunculosis  occurring  in  per- 
fectly healthy  people,  sugar  sometimes  appears  in  the  urine  and  vanishes 
after  the  recovery  from  the  furunculosis.  In  hospitals  where  the  anti- 
sepsis is  defective  furuncle  epidemics  sometimes  arise. 

Treatment  of  a  Furuncle. — The  best  treatment  of  a  furuncle  is  early 
incision  under  local  anaesthesia  with  cocaine  or  ether  spray,  to  alleviate 
the  painful  tension  and  to  provide  an  escape  for  the  pus.  Very  often 
it  is  possible  to  prevent  a  furuncle  from  developing  by  opening  the 
small  acne  pustule  as  soon  as  it  forms  and  disinfecting  it  with  a  one- 
tenth-per-cent.  solution  of  bichloride  of  mercury.  In  large,  fully 
developed  furuncles  a  cruciform  incision  should  be  made  and  the 
purulent  masses  carefully  scraped  out.  Ointment  dressings  of  boric- 
acid  ointment  or  vaseline  with  iodoform  are  better  than  dry  dressings. 
Much  time  used  to  be  lost  in  the  treatment  of  furunculosis  by  a  purely 
symptomatic  procedure,  such  as  the  employment  of  ice  and  warm, 
moist  applications.  When  there  is  an  extensive  infiltration  of  the 
parts  surrounding  the  furuncle,  the  moist,  warm  applications  are  no 
doubt  serviceable ;  but  the  main  point  is  always  to  lessen  the  tension 
by  an  incision  at  the  earliest  possible  moment,  and  to  provide  a  means 
of  escape  for  the  pus,  in  order  to  prevent  the  development  of  a  cellu- 
litis with  extensive  necrosis  of  tissue.  As  an  abortive  treatment  for 
furuncles  the  parenchymatous  injection  of  three  per  cent,  carbolic 
acid  or  the  application  of  a  drop  of  pure  carbolic  acid  are  sometimes 
employed. 

The  treatment  for  general  furunculosis  consists  in  the  use  of  luke- 
warm baths,  in  regulating  the  diet,  and  in  the  internal  administration 
of  arsenic.  The  local  treatment  is  in  general  the  same  as  that  given 
above.  Ten  per  cent.  /3-naphthol  paste  and  10-50  per  cent,  resorcin 
paste  are  also  useful.  In  diabetes,  regulation  of  the  diet  is  particularly 
important  (meat,  wine).  It  is  well  known  that  in  diabetes  extensive 
gangrenous  processes  sometimes  occur  in  conjunction  with  a  furuncle  ; 
in  this  condition  the  knife  should  be  used  with  caution. 

4.  Carbuncle. — By  carbuncle  is  understood  a  collection  of  furuncles 
lying  close  together,  giving  the  skin  the  appearance  of  being  perfo- 
rated like  a  sieve  by  separate  foci  of  inflammation.  Here  also  we 
generally  have  to  do  with  infection  by  the  Staphylococcus  pyogenes 
aureus  and  alhus.     The  carbuncle  has  a  more  pronounced  tendency 


532    INJURIES  AND  SURGICAL   DISEASES   OF  THE   SOFT   PARTS. 

than  the  furuncle  to  extend  peripherally.  It  occurs  particularly  on 
the  neck,  back,  buttocks,  cheeks,  and  lips.  The  carbuncle  in  healthj 
people,  as  a  general  thing,  is  not  dangerous ;  but  it  can  become  com- 
plicated with  extensive  phlegmonous  suppuration  and  necrosis  of  the 
skin  and  deeper  tissues,  with  venous  thromboses,  and  may  terminate 
fatally  from  septicaemia  or  pysemia.  In  a  carbuncle  involving  the  lips, 
cheeks,  or  neck  there  is  reason  for  fearing  an  extension  of  the  inflam- 
mation to  the  cranial  cavity,  as  cases  in  which  this  happens  often  run 
a  rapidly  fatal  course.  When  the  patient  has  diabetes  the  gangrenous 
destruction  of  tissue  is  often  very  considerable,  and  not  infrequently, 
as  a  result  of  the  extensive  gangrene,  and  in  spite  of  energetic  and 
suitable  local  surgical  treatment,  death  will  occur  from  sepsis  or 
pyaemia. 

The  Treatment  of  a  Carbuncle  is  essentially  the  same  as  for  a  fu- 
runcle, and  the  incisions  should  be  made  as  early  as  possible.  Their 
number  will  depend  upon  the  extent  of  the  inflammation,  though  in 
small  carbuncles  it  is  sufficient  to  make  one  longitudinal  or  cruciform 
incision  down  to  healthy  tissue.  If  the  suppuration  and  necrosis  of 
the  tissues  are  sufficiently  far  advanced,  I  remove  the  softened  gan- 
grenous and  suppurating  parts  with  a  sharp  spoon,  scissors,  and  for- 
ceps, and  disinfect  the  focus  most  carefully  with  a  one-tenth-per-cent. 
solution  of  bichloride  of  mercury.  For  dressings  I  prefer  iodoform, 
dermatol,  or  zinc  oxide  with  boric  ointment  or  vaseline.  Moist  warm 
applications  are  excellent  for  softening  areas  containing  an  inflamma- 
tory infiltration.  Later  on  we  should  always  be  on  the  alert  to  pre- 
vent any  burrowing  of  pus,  any  retention  of  the  discharges,  etc.  Ac- 
cording to  the  extent  of  the  inflammation,  the  antiseptic  dressing 
should  be  changed  once  or  twice  a  day,  or  every  two  to  three  days. 
This  energetic  operative  treatment  of  a  carbuncle  is  better  than  the  old- 
fashioned  symptomatic  method,  which  avoided  the  use  of  the  knife. 
The  strength  of  old  people,  in  particular,  should  be  sustained  by  nu- 
tritious food,  by  wine,  etc.  Cutaneous  defects — loss  of  skin  substance 
on  the  face,  for  example — should  be  remedied  by  plastic  operations. 

The  anthrax  carbuncle  {pustula  maligna)  is  described  in  §  77,  and 
acute  inflammation  of  the  skin  and  cellular  tissue  (cellulitis)  in  ^  70. 

5.  The  Chronic  Inflammations  of  the  Skin  and  Subcutaneous  Cellular 
Tissne — Lupus. — Of  the  chronic  inflammations  of  the  skin  I  shall  first 
take  up  lupus,  a  disease  which  is  to  be  regarded,  in  the  main,  as  a 
tuberculosis  of  the  skin  (see  §  S3).  As  a  proof  of  this,  tubercle  bacilli 
are  found  in  the  lupus  foci  (see  page  416).  By  the  inoculation  of 
lupous  tissue  into  the  peritonseum  or  the  anterior  chamber  of  the  eye 
of  guinea-pigs  and  rabbits  unquestionable  typical  tuberculosis  is  pro- 


§93.]      THE  DISEASES  OF  THE  SKIN  AND   CELLULAR  TISSUE.        533 

diiced.  The  toxines  of  tubercle  bacilli  can  also,  as  stated  on  page  418, 
cause  cutaneous  diseases  in  tubercular  subjects ;  tubercle  bacilli  can 
not  be  demonstrated  in  these  chronic  exanthematous  lesions  (Boeck). 
As  regards  the  j)athological  changes  in  lupus,  I  must  refer  the  reader 
to  the  detailed  description  of  tuberculosis  in  §  83 ;  we  shall  discuss 
here  only  the  following  clinical  aspects  of  the  disease.  Lupus  is  par- 
ticularly apt  to  occur  on  the  face,  though  it  also  appears  on  other  por- 
tions of  the  body,  such  as  the  extremities.  Lupus  originates  by  the 
tubercle  bacilli  finding  lodgment  in  the  normal  pores  of  the  skin,  or 
in  some  wound  which  may  be  a  very  small  cutaneous  injury  or  an 
abrasion.  !N^ot  infrequently  it  may  be  proved  to  have  originated  by 
inoculation  or  by  contact  with  people  having  tuberculosis.  This  lupus 
coming  from  inoculation,  as  a  result  of  a  direct  infection,  and  occurring 
in  individuals  otherwise  perfectly  healthy,  I  believe  to  be  much  more 
common  than  has  hitherto  been  supposed.  Besnier,  Unna,  and  Phil- 
lipson  have  observed  an  acute  dissemination  of  lupus  nodules  over  the 
entire  body.  In  lupus  of  the  skin  the  pathological  changes  consist  in 
the  formation  of  small  nodules  made  up  of  typical  tubercles.  The 
nodules  may  disappear  by  absorption,  or  break  down  and  suppurate, 
giving  rise  to  corresponding  losses  of  substance  in  the  skin — i.  e., 
ulcers.  In  combination  with  the  nodules  and  ulcers  a  diifuse  infil- 
tration and  hyperplasia  of  the  tissues  is  frequently  observed.  The 
epithelium  often  proliferates  in  an  atypical  form  growing  into  the 
subcutaneous  cellular  tissue  and  giving  rise  to  formations  similar  to 
carcinoma. 

As  regards  further  pathological  changes  in  lupus,  I  must  refer  the 
reader,  as  I  have  before  remarked,  to  the  detailed  description  of  tuber- 
culosis in  §  83.  We  shall  confine  ourselves  here  to  its  clinical  and 
therapeutic  aspects. 

Clinically,  three  forms  are  distinguished  :  lupus  maculosus  (or  lupus 
exfoliativus),  lupus  exulcerans,  and  lupus  hypertrophicus.  In  lupus 
maculosus,  red  or  yellowish-brown  smooth  spots  are  formed,  with  a 
cracked,  exfoliating,  epidermic  covering  (lupus  exfoliativus).  In  some 
cases  lupus  maculosus  extends  rapidly  from  the  original  location  with 
the  formation  of  circumscribed  areas  and  symptoms  of  fever  and  dis- 
turbance of  the  general  health ;  such  patients  sometimes  die  with  the 
symptoms  of  general  sepsis.  If  there  is  destruction  of  tissue,  corre- 
sponding ulcers  result,  generally  covered  with  crusts  (lupus  exulce- 
rans), which  may  lead  to  extensive  destruction  of  the  skin  and  adjoin- 
ing parts,  especially  upon  the  nose,  cheeks,  lips,  etc.  (Fig.  367).  Yery 
often  the  process  extends  at  the  peripheral  portion  of  the  diseased 
area,  while  in  the  centre  a  smooth  or  seamed  cicatricial  tissue  develops. 


534    INJURIES  AND  SURGICAL   DISEASES   OF   THE   SOFT   PARTS. 


Fig.  367. — Lupus  of  the  face  (Esinarch). 


In  lupus  exulcerans  there  will  be  found,  in  addition  to  the  tubercle 
bacilli,  pus  cocci,  especially  the  Staphylocuccus  pyogenes  aureus.  Ac- 
cording to  Leloir  and  Tavernier,  the 
ulcerative  changes  occurring  in  lupus 
are  mainly  due  to  the  pus  cocci  which 
come  from  without,  Cazin  describes 
hyaline  flakes  in  the  connective  tissue 
of  ulcerating  lupus.  They  take  on  a 
deep  stain,  with  crystal  violet  (accord- 
ing to  Kiiline),  and  are  similar  to  the 
bodies  found  by  Russel  in  epithe- 
liomata.  The  nodular  form  of  lupus 
is  called  lupus  hypertrophicus  (Fig. 
368).  When  there  is  a  marked  new 
formation  and  dilatation  of  vessels 
the  process  is  called  lupus  telangiec- 
tades.  Between  these  different  classes 
there  are  numerous  transition  forms, 
which  often  occur  close  beside  one 
another  in  the  same  lupous  collection.  The  clini- 
cal course  of  lupus  is  usually  very  chronic.  It 
generally  begins  in  children  from  four  to  twelve 
years  of  age,  or  later,  and  often  lasts  for  many 
years.  In  consequence  of  the  losses  of  substance 
and  marked  cicatricial  shrinkage  or  diiiuse  cicatri- 
cial thickening,  bad  deformities  result,  particular- 
ly on  the  face,  the  treatment  of  which  will  be  dis- 
cussed in  the  Regional  Surgery.  JSTot  infrequently 
patients  with  lupus  die  of  tuberculosis  of  the  in- 
ternal organs — of  the  lungs,  for  example.  Some- 
times epitheliomata  originate  in  lupous  foci  and 
cicatrices  (Fig.  369). 

Treatment  of  Lupus. — The  treatment  of  lupus 
consists,  in  addition  to  a  suitably  invigorating 
mode  of  life  (see  §  83,  Tuberculosis),  mainly  in 
adopting  energetic  local  surgical  measures,  such 
as  excision  of  the  lupous  disease  or  its  destruction 
with  the  sharp  spoon  (Yolkmann,  page  77),  the 
Paquelin  thermo-cautery  (see  page  79),  or  the  gal- 
vano-cautery  (see  page  80).  The  earlier  a  lupus  is  removed  by  extir- 
pation with  the  knife  the  sooner  may  permanent  recovery  be  expected. 
The  wound  from  the  excision  is  either  simply  closed  by  sutures,  or, 


Fig.  368.— Hypertrophic 
lupus  of  the  hand 
(Busch). 


§  93.]      THE   DISEASES   OF   THE  SKIN   AND   CELLULAR  TISSUE. 


535 


if  this  is  impossible  on  account  of  too  great  a  loss  of  substance,  tlie 
cutaneous  defect  is  remedied  by  plastic  operations  (see  page  140),  or 
Idj  Thiersch  skin  grafts  (see  page  147).  The  plastic  operation  or  trans- 
plantation of  skin  prevents  the  troublesome  consequences  produced  by 
cicatricial  contraction,  and  is  especially  valuable  in  preventing  recur- 
rences. By  excision  of  the  lupus  and  making  use  of  Thiersch  skin 
grafts,  particularly  on  the  face,  I  have  obtained  very  satisfactory 
results  and  have  prevented  or  overcome  bad  deformities.  Punctures 
made  with  a  galvano-cautery  curved  at  the  end,  or  with  the  fine  tip 
of  the  Paquelin  cautery,  are  exceedingly  serviceable  for  the  pure  macu- 
lar or  exfoliating  lupus,  such  as  occurs  upon  the  face.  Thayer  recom- 
mends destruction  of  lupus  by  the  sun's  rays  which  are  concentrated 
by  means  of  a  lens  upon  the  lupous  skin-area;  the  wound  resulting 
from  the  burn  heals  quickly  and  well.  The  Rontgen  rays  have  been 
used  in  the  same  way.  We  destroy 
lupus  exulcerans  and  hypertrophicus 
by  vigorous  scraping  with  the  sharp 
spoon,  or  by  using  the  Paquelin  ther- 
mo-cautery,  in  case  excision  is  impos- 
sible. I  have  given  up  the  use  of  caus- 
tics altogether  (caustic  potash,  copper 
.sulphate,  nitric  or  chromic  acid,  etc.). 
Kaczanowski  speaks  well  of  cauteriza- 
tion with  powdered  jDermanganate  of 
potassium,  which  is  applied  to  the 
lupous  skin  area  in  a  layer  two  to  five 
millimetres  thick.  Liebreich  recom- 
mends the  subcutaneous  injection  of 
<3antharidic  acid  or  of  the  cantharidate 
of   potassium.      The  numerous  other 

remedies,  chiefly  antiseptics,  and  many  of  the  ointments  which  have 
been  recommended  for  the  local  treatment,  are  in  my  experience  of 
little  value ;  permanent  cures  are  rare.  In  cases,  however,  that  are 
not  adapted  to  excision  pyrogallic  acid  in  ointment  form  (1  :  10),  sali- 
cylic-creosote plaster  (Unna),  Lassar's  paste  or  Unna's  raerciirial  plaster 
are  very  useful,  particularly  after  previous  scraping  with  a  sharp  spoon 
or  puncture  with  the  thermo-  or  galvano-cautery.  The  constitutional 
treatment  by  strengthening  food,  good  air,  sea  baths,  proper  climate, 
etc.,  is,  next  to  the  energetic  local  treatment,  of  the  greatest  impor- 
tance, especially  for  preventing  any  recurrence  of  the  disease.  The 
treatment  of  lupus  by  Koch's  tuberculin  is  described  on  page  431. 
Actual  cures  by  tuberculin  are  rarely  obtained.     I  have  never  seen 


Fig.  -369. — Epithelioma  of  the  left  orbital 
region  in  a  lupous  patient  forty-eight 
years  old. 


536 


INJURIES  AND  SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 


one.  In  the  course  of  the  treatment,  after  apparent  improvement  has 
occurred  in  the  affected  portion  of  skin,  I  have  excised  a  piece  of  the 
latter  and  found  in  the  deeper  parts,  under  the  liealed  external  cuta- 
neous covering,  eruptions  of  new  tubercles. 

0.  Ulcers  of  the  Skin. — By  ulceration  is  understood  a  granulating 
defect  in  the  skin  accompanied  by  a  suppurative  breaking  down  of  the 
granulations,  which  shows  no  tendency  to  heal.     Ulcers  present  great 

differences  as  regai-ds  their  size,  charac- 
ter, and  course.  The  causes  of  an  ulcer, 
its  location,  and  the  general  condition 
of  the  patient,  have  a  most  important 
bearing  upon  its  clinical  course.  Ac- 
cording to  the  intensity  of  the  reactive 
inflammation,  we  make  a  distinction 
between  atonic  or  torpid  ulcers  and 
inflammatory  ulcers.  There  are  great 
differences  in  the  shapes  of  ulcei's,  some 
being  round,  others  half-moon-shaped, 
circular,  or  irregular  in  outline.  The 
surface  of  an  ulcer  may  be  smooth  or 
sunken,  or  more  or  less  prominent.  Ac- 
cording to  the  character  of  the  surface 
of  the  ulcer  or  its  base  we  distinguish 
oedematous,  h?emorrhagic,  gangrenous, 
sloughing,  and  fungous  ulcers ;  the  lat- 
ter are  marked  by  prominent,  spongy, 
inflamed  gi-anulations.  Yery  often  a. 
canal,  or  fistula,  as  it  is  called,  extends 
from  the  ulcer  to  a  greater  or  less  depth 
into  the  subjacent  parts.  The  flstulse  (from  fistula^  a  pipe),  as  a  gen- 
eral thing,  originate  from  some  deeply  placed  focus  of  inflammation 
which  has  gradually  made  its  way  to  the  surface.  The  edges  of  an 
ulcer  may  be  either  more  or  less  normal,  flat  or  swollen,  or  hard  and 
like  a  wall  (callous  ulcer),  or  undermined  (sinuous  ulcer).  Phagedenic 
ulcers  {(paryeSaiva,  from  (f^ajelv,  to  eat)  are  those  which  increase  more 
or  less  rapidly  in  circumference  analogously  to  the  hospital  gangrene 
of  wounds  (see  §  Y2). 

The  causes  of  ulcers  are  very  numerous,  and  are  sometimes  local 
and  sometimes  constitutional.  Ulcers  originate  from  traumatisms  of 
various  descriptions,  from  stasis,  or  from  the  suppurative  breaking 
down  of  tumours  and  products  of  inflammation,  such  as  syphilis  (§  84), 
tuberculosis  (§  83)  lupus  and  leprosy  (§  85).      The  varicose  ulcer  of  the 


■.^L,' 
'  ^ 


Fig.  370. — Varicose  ulcer  of  the  leg  (a), 
resulting  from  varicose  veins. 


§93.]      THE  DISEASES   OP  THE   SKIN  AND  CELLULAR  TISSUE.        537- 

leg,  of  so  common  occurrence,  develops  from  inflammatoiy  stasis  in  tlie 
leg  in  conjunction  with  dilated  veins  (varices.  Fig.  370).  When  varices 
exist,  any  mild  inflammation,  a  slight  traumatism,  or  an  eczema  vesicle 
may,  as  a  result  of  the  venous  stasis,  give  rise  to  an  ulcer,  since  repair,  or 
the  formation  of  normal  granulation  tissue,  is  rendered  difficult  by  the 
disturbance  in  the  circulation.  Ulcers  may  also  originate  when  in  any 
portion  of  the  body  a  necrosis  of  the  skin  is  brought  about  by  pressure. 
In  this  class  belong  the  bedsores  which  occur  upon  the  sacrum,  over 
the  trochanters,  on  the  heel,  etc.,  in  individuals  whose  nutrition  is 
impaired  and  whose  circulation,  as  a  result  of  anaemia  and  cardiac  weak- 
ness, is  imperfect.  Trophoneurotic  gangrene  and  ulcerative  processes 
occur  in  paralytic  conditions  and  other  diseases  of  the  nervous  sys- 
tem. Great  interest  attaches  to  the  often  multiple,  neurotic  ulcers 
of  the  skin  occurring  in  conjunction  with  gangrene  of  the  skin,  as  a 
result  of  ascending  neuritis  with  secondary  disease  of  certain  central 
portions  of  the  spinal  cord  (Doutrelepont,  Kopp,  and  others).  The 
soft  and  hard  chancres  have  been  mentioned  in  §  84. 

Pendjeh  Ulcer. — A  peculiar  ulcer  occurs  in  Peudjeli  in  the  form  of  a 
plague,  which  in  the  last  few  years  has  attacked  principally  the  Russian 
troops  in  Transkaspian,  more  especially  in  the  department  of  Murghab.  In 
1885  ninety  per  cent,  of  all  the  troops  in  this  department  suffered  from  the 
disease.  The  latter  is  characterised  by  the  formation  of,  e.  g.,  twenty  to  forty 
to  sixty  to  ninety  vesicles  and  ulcers  over  the  entire  body  without  marked 
disturbance  of  the  general  health.  The  disease  lasts  from  three  to  six  months 
— on  an  average  three  and  a  half  months.  The  cause  of  the  ulcers  is  thought 
to  be  a  micro-organism  occurring  in  the  Murghab  water  which  reaches  the 
human  body  with  the  mist  and  dust  and  infects  the  skin.  The  treatment  of 
the  ulcers  is  the  usual  one.  Subor'recommends  a  five-per-cent.  alcoholic  solu- 
tion of  methyl-violet,  which  is  painted  upon  the  surface  of  the  ulcer  after 
the  latter  has  been  disinfected  with  bichloride.  The  ulcers  are  then  left 
exposed,  only  the  larger  ones  being  covered  with  gauze  and  cotton. 

Treatment  of  Ul^rs. — The  treatm.ent  of  ulcers  varies  with  their 
cause.  The  latter  must  always  be  carefully  taken  into  account  if  an 
ulcer  is  to  be  properly  treated  ;  for  example,  a  constitutional  dyscrasia, 
like  syphilis,  tuberculosis,  or  bad  nutrition,  nervous  diseases,  etc.,  must 
at  the  same  time  be  attended  to.  The  treatment  of  every  ulcer  should 
be  conducted  upon  antiseptic  principles.  Dressings  with  iodoform, 
dermatol,  oxide  of  zinc,  bismuth,  naphthaline,  with  or  without  oint- 
ments (boric-acid  ointment),  are  excellent.  The  numerous  antiseptic 
materials  for  covering  a  wound  (powder,  ointments,  etc.)  are  enumer- 
ated in  §§  45,  46.  Gangrenous  phagedenic  ulcers  are  best  treated  by 
scraping  them  with  a  sharp  spoon,  by  cauterisation  with  caustic  potash, 
the  Paquelin  or  gal vano- cautery.     In  large  ulcers  the  use  of  perma- 


538    INJURIES  AND  SURGICAL    DISEASES  OF   THE  SOFT   PARTS. 

nent  irrigation  (page  181),  or  a  bath  for  the  entire  body  (page  182),  are 
sometimes  advantageous.  It  is  very  important  to  prevent  any  stasis, 
any  disturbance  of  circulation,  by  placing  the  parts  in  a  suitable  posi- 
tion, by  rest,  etc.  In  varicose  ulcers  of  the  leg,  satisfactory  results 
are  often  obtained  by  enveloping  the  leg  in  Martin's  elastic  bandage, 
which  possesses  the  great  advantages  of  not  confining  the  patient  to 
bed  and  of  allowing  him  to  attend  to  his  business.  JSI^ot  infrequently, 
however,  Martin's  elastic  bandage  is  not  well  borne,  as  it  excites  a  per- 
sistent eczema,  which  should  be  treated  as  described  on  page  528.  If 
the  borders  of  the  ulcer  are  slightly  movable,  circumcision  of  the  ulcer 
is  an  excellent  means  of  making  it  possible  for  the  base  of  the  ulcer  to 
contract,  thus  hastening  the  healing  (Nussbaum ).  The  circumcision  is 
performed  by  carrying  an  incision  through  the  skin  down  to  the  fascia, 
around  the  ulcer  some  one  to  two  to  three  centimetres  from  its  edge. 
A  very  good  method  of  treatment  of  varicose  ulcers  of  the  leg  con- 
sists in  ligation  of  the  internal  saphenous  vein  on  the  inner  side  of  the 
thigh  about  a  hand's  breadth  above  the  internal  condyle  of  the  femur, 
with  or  without  circumcision  of  the  ulcer  (Trendelenburg.  Perthes 
reported  sixty-three  cases  of  varicose  veins  of  the  leg  which  were 
treated  in  this  way,  among  which  were  fifty-four  ulcers  of  the  leg ;  the 
latter  healed  in  most  cases  soon  after  the  operation.  For  hastening 
the  growth  of  skin  over  the  ulcer,  Thiersch's  method  of  skin  gi*afting 
(§  42)  is  particularly  serviceable  after  previously  freshening  or  scrap- 
ing o2  the  base  of  the  ulcer  with  a  sharp  spoon.  Circumcision  of  the 
ulcer  can  be  combined  to  good  advantage  with  skin  grafting.  The 
latter  procedure  has  taken  the  place  of  the  implantation  of  skin  flaps 
with  pedicles  taken  from  immediately  adjoining  or  distant  portions  of 
the  body,  and  which  were  formerly  much  in  vogue.  Maas  in  particu- 
lar has  obtained  good  results  from  the  implantation  of  pedunculated 
skin  flaps  taken  from  a  distant  portion  of  the  body.  He  recommends 
that  the  flap  to  be  transplanted  be  cut  as  much  as  possible  in  the 
direction  of  the  course  of  the  vessels,  and,  after  previously  removing 
the  layer  of  granulations  in  the  defect  with  a  sharp  spoon,  the  edges  of 
the  ulcer  should  be  fi*eshened  all  around  ;  the  flap  is  then  united  by 
sutures  to  the  borders  of  the  defect  and  by  buried  sutures  to  its  sur- 
face. The  wounded  and  exposed  portion  of  the  flap  is  prevented 
from  drying  by  being  covered  with  a  plentiful  amount  of  boric-acid 
ointment  spread  on  gauze.  An  antiseptic  dressing  is  placed  over 
everything,  and  the  portions  of  the  body  under  treatment  are  com- 
pletely immobilised  by  a  plaster-of-Paris  dressing.  Whenever  possi- 
ble, the  dressing  is  left  undisturbed  for  fourteen  days  and  then  the 
pedicle  of  the  flap  is  divided.     In  this  way  a  flap  can  be  transplanted 


§93.]      THE  DISEASES  OF   THE  SKIN  AKD   CELLULAR   TISSUE.        539 

from  the  breast  to  the  arra,  from  one  leg  to  the  other,  and  from  the 
upper  extremity  to  the  face,  and  joints  can  thus  be  made  movable 
which  were  previously  stiffened  by  cicatricial  contractures — i.  e.,  had 
lost  their  function.  In  conclusion,  I  should  mention  that  hypertrophic 
bone  under  the  base  of  an  ulcer — in  the  tibia,  for  example — must  be 
carefully  levelled  off  with  the  chisel ;  any  undermined  boj-ders  around 
an  ulcer  should  be  excised,  fistulse  should  be  laid  open,  etc.  In 
many  cases  of  extensive  ulceration,  when  repair  is  impossible  or  the 
affected  limb  is  useless,  am^Dutation  may  be  indicated.  It  should  be 
borne  in  mind  that,  as  a  result  of  the  exposure  and  erosion  of  a  vessel 
by  an  ulcer,  a  serious  or  even  fatal  haemorrhage  may  occur,  unless  aid 
can  be  speedily  obtained. 

Scurvy  (Scorbutus)  and  the  Ulcers  which  occur  with  it.— Ulcers  also  occur 
ill  scurvy,  especially  on  the  gums,  in  the  upper  portion  of  the  cavity  of  the 
mouth,  and  on  the  lips.  The  gums  swell  as  a  result  of  hgemorrhages,  become 
bluish  red,  and  then  break  down  into  peculiar  bluish-red  ulcers  with  bluish- 
green  borders  and  granulations,  which  bleed  easily.  In  other  respects  scurvy 
is  characterised  by  hgeinorrhages  into  the  skin  and  the  subcutaneous  cellular 
tissue  (purpura  scorbutica),  into  the  muscles,  joints,  and  from  the  intestine, 
by  general  emaciation,  ana?mia,  and  hydremia.  Scorbutus  now  occurs  less 
often  than  formerly.  It  is  to  be  regarded  essentially  as  a  severe  cachexia,  or 
a  general  disturbance  of  nutrition,  involving  particularly  the  walls  of  the 
blood-vessels.  Whether  micro-organisms  play  any  part  in  the  origin  of 
scurvy  is  still  a  matter  of  uncertainty.  The  disease  occurs  endemically, 
especially  among  individuals  who  live  under  unfavourable  external  condi- 
tions, such  as  sailors  who  have  eaten  for  a  long  time  only  salted  meat  with- 
out any  fresh  vegetable  food.  It  also  occurs  in  damp,  badly  ventilated  and 
crowded  quarters  (prisons,  barracks,  etc.).  Scorbutus  has  only  a  slight  in- 
terest for  the  surgeon,  so  that  we  must  refer  the  reader  to  the  text-books  on 
internal  medicine.  The  prognosis  of  this  affection,  which  for  the  most  part 
runs  a  chronic  course,  depends  upon  the  possibility  of  speedily  removing  the 
unfavourable  hygienic  conditions.  Hence  the  treatment  consists  mainly  in 
providing  good  dwellings  and  good  food  (fresh  meat,  fresh  vegetables).  In 
addition  to  this,  acids — particularly  vegetable  acids — are  beneficial  in  the 
form  of  fresh  watercress  and  sorrel.  Since  legislation  has  provided  that 
ships,  prisons,  etc.,  should  be  well  supplied  with  food,  and  that  the  inmates 
of  prisons  obtain  fresh  vegetables  in  sufficient  quantity,  scurvy  has  become 
less  common.  The  ulcers  in  the  mouth  should  be  treated  by  mild  cauterisa- 
tion with  nitrate  of  silver,  iodoform,  and  gargles  of  three  per  cent,  chlorate 
of  potash  or  boric  acid. 

Other  Anomalies  of  Granulating  "Wounds. — In  addition  to  the  ulcerative 
destruction  of  granulations  there  are  still  other  anomalies  of  granulating 
wounds  which  interfere  with  their  healing,  and  these  we  shall  discuss  briefly. 
By  fungous  or  spongy  granulations  are  understood  those  which  project  above 
the  level  of  the  surface  of  the  wound  in  the  form  of  a  fungus.  Soft  exuber- 
ant granulations  like  these  are  observed  in  tuberculosis  especially,  and  also 
when  there  are  any  hindrances  to  healing,  such  as  those  due  to  induration  of 


540     INJURIES  AND   SURGICAL   DISEASES   OF  THE  SOFT   PARTS. 


the  surrounding  parts,  or  to  the  presence  of  a  foreign  body,  or  a  necrotic 
piece  of  bone — a  sequestrum,  as  it  is  called — in  the  depths  of  the  wound. 
The  treatment  of  these  fungous  granulations  consists  in  removing  the  above- 
mentioned  causes  and  in  applying  energetic  cauterisation  with  the  nitrate- 
of-silver  stick.  Pressure  also  does  good  service.  When  necessary,  the  gran- 
ulations may  be  removed  by  a  sharp  spoon,  the  thermo-cautery,  or  simply  by 
the  knife  or  scissors,  and  the  wound  surface  covered  with  very  small  pieces 
of  skin  by  Tlnerschs  method  (§  42). 

Irritable  Ulcer. — By  irritable  ulcer  very  painful  granulations  are  meant, 
which  bleed  easily.  It  is  not  known  upon  what  the  painfulness  of  these 
gi'anulations  really  depends,  and  it  is  the  more  remarkable  from  the  fact 
that  granulation  tissue  usually  possesses  no  nerves.  The  affection  is  ob- 
served most  commonly  in  anaemic  or  hysterical  individuals.  The  best  treat- 
ment consists  in  the  application  of  desiccating  powder  dressings  (iodoform, 
bismuth,  dermatol),  or  in  flie  removal  of  the  painful  granulations  by  caustics, 
or,  bettei',  wdth  scissors  or  the  sharp  spoon,  followed  by  transplantation  of 
skin,  etc. 

7.  Elephantiasis. — By  elepliantiasis  (elephantiasis  Arabum  or  pachy- 
dermia acquisitai  is  uuderstood  an  extensive  liypei-plastic  thickening 

of  the  skin  and  subcutaneous  cel- 
lular tissue  over  large  portions  of 
the  body,  most  frequently  observed 
upon  the  lower  extremities  and 
genitals  (Fig.  371).  The  hyper- 
plasia of  the  tissues  may  develop 
in  conjunction  with  various  chronic 
and  frequently  recurring  inflam- 
mations, such  as  chronic  eczema, 
ulcerations,  chronic  periostitis  and 
osteomyelitis,  erysipelatous  and 
lymphangitic  processes,  lymph  sta- 
sis, injuries  to  nerves,  etc.  A  sec- 
ond form  of  elephantiasis  is  the 
result  of  a  chronic  affection,  the 
nature  of  which  is  still  unknown, 
and  occurs  endemically  in  tropical 
and  subtropical  countries  (Central 
America,  Arabia,  India),  while  in 
Europe  only  sporadic  cases  are  ob- 
served. In  its  epidemic  form  the 
process  is  due  in  many  instances 
to  the  presence  of  the  filaria  Bancrofti  (or  medinensis),  which,  with  its 
embryos,  inhabits  the  lymphatic  vessels  and  causes  lymph  stases  and 
inflammations,  particularly  of  the  external  genitals,  the  thigh,  and  peri- 


Fio.  371. — -Eiepiiantiasis  in  a  native  of  Samoa ; 
removal  of  the  scrotum,  which  weighed 
seventy-eight  pounds,  followed  by  recov- 
ery (Koniger). 


§93.]      THE   DISEASES   OF  THE  SKIN  AND   CELLULAR   TISSUE.        541 

toneal  cavity.  The  invasion  of  the  filaria  does  not  in  everj  case  give 
rise  to  elephantiasis,  and  as  a  matter  of  fact  the  parasites  have  not 
been  found  in  the  majority  of  cases.  The  thread-like  worm  is  8  to  10 
centimetres  long,  and  its  larvae  about  0.35  millimetres.  They  probably 
enter  the  human  organism,  the  lymphatic  vessels,  and  the  blood  from 
the  intestine  (Mansou,  Scheube). 

The  portions  of  skin  involved  in  the  elephantiasis  are  sometimes 
dense  and  hard  (elephantiasis  dura)  and  sometimes  made  up  of  soft, 
greyish-white  tissue  (elephantiasis  mollis),  and  often  contain  greatly 
dilated  lymphatic  vessels  (elephantiasis  lymphangiectatica).  Elephan- 
tiasis is  occasionally  congenital,  and  may  be  a  result  of  abnormal  devel- 
opment and  new  formation  of  blood  and  lymphatic  vessels  (elephanti- 
asis congenita  telangiectodes  and  E.  lymphangiectodes).  (See  also 
Tumours.)  In  rare  instances  an  inherited  elephantiasis  is  observed. 
Some  forms  of  tumours,  such  as  the  soft  diifuse  fibromata,  neuro- 
fibromata,  and  plexif  orm  neuromata,  may  resemble  a  circumscribed  ele- 
phantiasis. 

Treatment  of  Elephantiasis. — The  treatment  of  elephantiasis  in  the 
beginning  of  the  disease  is  directed  towards  the  cause,  particularly  the 
inflammatory  changes  in  the  aifected  portions  of  the  body.  Envelop- 
ing the  parts  in  elastic  bandages,  placing  them  in  an  elevated  position, 
injections  of  alcohol,  hgation  of  the  main  afferent  artery,  punctate  cau- 
terisation, repeated  spindle-shaped  excisions,  and  total  removal  of  an 
elephantiatic  scrotum  or  of  the  affected  extremities  by  amputation  or 
disarticulation,  have  all  been  employed  (see  Regional  Sui'gery). 

Myxcedema  (see  also  Regional  Surgery). — Myxoedema  is  a  well- 
characterised  disease  of  great  pathological  interest  which  is  much  more 
common  in  some  countries  than  in  others.  It  has  been  studied  'chiefly 
by  Gull,  Ord,  Yirchow,  Horsley,  Eiselsberg,  Ewald,  and  others.  There 
have  been  differentiated  an  idiopathic,  a  post-operative,  and  an  infantile 
form  (sporadic  cretinism).  The  disease,  which  was  first  described  by 
Gull  in  1873  as  the  "  cretinoid  condition,"  affects  women  more  often 
than  men,  especially  those  of  middle  age.  There  is  always  a  destruc- 
tive change,  such  as  fibroid  degeneration,  interstitial  connective-tissue 
development,  or  other  disease  of  the  thyroid  gland,  the  latter  being 
sometimes  enlarged  and  sometimes  atrophic.  Myxoedema  has  also 
been  observed  in  connection  with  syphilitic  disease  of  the  thyroid 
gland.  The  interstitial  connective-tissue  growth  generally  present  in 
the  thyroid  is  mainly  the  result  of  an  inflammatory  process,  and  is  also 
very  frequently  found  in  the  skin  and  in  the  internal  organs.  A  pro- 
nounced excess  of  mucin  is  found  in  the  skin  and  blood  ;  the  amount 
of  haemoglobin  in  the  blood  is  diminished,  while  the  amount  of  red 


542    INJURIES  AND  SURGICAL  DISEASES   OF   THE  SOFT   PARTS. 

corpuscles  and  fibrin  varies,  being  sometimes  diminished  and  sometimes 
increased.  The  power  of  the  red  blood-corpuscles  to  take  up  oxygen 
may  be  greatly  diminished.  The  skin,  particularly  of  the  face  and 
extremities,  is  characteristically  swollen.  There  are  also  disturbances 
of  speech,  of  motion,  and  of  intellect,  and,  in  brief,  a  remarkable 
decline  of  the  bodily  and  mental  functions.  In  youthful  individuals 
the  normal  development  does  not  take  place  (dwarfs,  etc.).  Myxoedema 
is  extremely  rare  in  childhood.  I  observed  a  case  in  a  boy  three  years 
of  age  due  to  congenital  absence  of  the  thyroid  gland. 

By  experimental  extirpation  of  the  thyroid  gland  in  animals,  and  by 
its  total  extirpation  in  man,  there  is  produced  a  form  of  disease,  the 
so-called  cachexia  strumipriva  or  thyreopriva,  which  corresponds  in 
all  respects  to  myxcedema,  and  hence  only  a  partial  i-emoval  of  the 
thyroid  gland  is  allowable  in  man.  Myxoedema  has  also  been  observed 
after  partial  extirpation  of  the  degenerated  gland  when  the  retained 
portion  atrophied  with  remarkable  rapidity  (Kohler).  Sometimes 
myxoedema  takes  several  years  to  develop  after  removal  of  a  goitre. 
Seldowitsch  observed  myxoedema  after  removal  of  an  accessor}^  gland 
at  the  base  of  the  tongue  (see  also  Regional  Sui-gery).  Schilf  and 
Eiselsberg  demonstrated  that  animals  withstand  total  extirpation  of 
the  thyroid  gland  if  their  own  thyroid  gland,  or  one  taken  from 
another  animal  of  the  same  species,  is  successfully  implanted  in  the 
peritoneal  cavity  and  resumes  its  normal  function  there.  The  function 
of  the  thyroid  gland,  which  is  to  prevent  the  accumulation  in  the 
body  of  mucin,  is  disturbed  in  myxoedema.  Therefore  myxoedema 
may  originate  from  operative  removal  as  well  as  from  degeneration  of 
the  thyroid  gland,  and  is  probably  identical  with  the  so-called  sporadic 
cretinism  which  occurs  in  children,  and  is  closely  related  to  endemic 
cretinism.  The  course  is  usually  chronic,  but  sometimes  acute.  The 
prognosis  was  at  one  time  very  unfavourable,  the  disease  usually  termi- 
nating by  death  in  a  few  years,  sometimes  with  tetanic  manifestations. 
In  recent  times  improvement  and  even  cures  have  taken  place  after 
the  internal  administration  of  the  thyroid  gland  of  sheep  and  calves. 

Treatment. — The  best  treatment  consists  in  the  administration  of 
the  thyroid-gland  material  from  sheep  and  calves.  Caution  is,  how- 
ever, necessary,  as  symptoms  of  poisoning  (collapse,  rapid  pulse,  car- 
diac weakness,  Graves's  disease,  etc.)  have  been  observed.  The  use  of 
the  fresh  thyroid  gland  is  much  less  often  followed  by  symptoms  of 
poisoning  than  is  the  administration  of  the  various  preparations  of  the 
dried  gland.^  The  thyroid-feeding  is  continued  as  long  as  possible,  and 
small  doses  should  be  used  at  first.  The  gland  has  also  been  used 
with  success  in  cases  of  obesity  and  different  skin  diseases.     In  the 


§93.]      THE  DISEASES  OP   THE  SKIN  AND   CELLULAR  TISSUE.        543 

case  of  adults  about  ten  grammes  of  the  fresh  gland  are  given  weekly 
and  in  children  about  five  grammes.  The  fat  and  outer  fibrous  capsule 
are  removed  in  as  aseptic  a  manner  as  possible,  the  gland  is  cut  into 
small  pieces,  spread  on  bread,  and  seasoned  with  salt  and  pepper. 
Various  thyroid  tablets  may  also  be  employed.  In  extreme  cases  the 
implantation  of  a  fresh  functionating  thyroid  gland  into  the  abdominal 
wall  could  be  tried  (Eiselsberg).  For  further  particulars  see  Eegional 
Surgery  (Goitre,  Graves's  Disease,  etc.). 

Scleroderma.— By  scleroderma  is  understood  a  circumscribed  or  more  dif- 
fuse hardening  of  the  skin,  occurring-  rather  suddenly  in  adults,  without 
external  causes,  and  either  remaining  stationary  or  gradually  extending,  and 
finally  terminating  in  atro- 
phy. In  scleroderma  the 
skin  is  as  hard  as  wood,  and 
the  disease  occurs  on  the 
trunk,  the  face,  and  the  ex- 
tremities. Its  nature  is  un- 
known. Anatomically,  Chi- 
ari  found  a  thickening  of  the 
fibrous  stroma  of  the  skin 
combined  in  places  with  an 
infiltration  with  leucocytes. 
It  is  probably  in  the  main 
an  interstitial  inflammation. 
Heller  found  in  one  case  an 
obliteration  of  the  thoracic 
duct.  The  treatment  con- 
sists in  massage,  baths,  soft- 
ening plasters,  and  plenty 
of  bodily  exercise  (gym- 
nastics, dancing,  running, 
work,  etc.). 

Scleroderma  neonato- 
rum, according  to  Langer,  is 
caused  by  a  stiffening  and 
hardening  of  the  subcuta- 
neous cellular  tissue  in  con- 
ditions of  collapse  and  low- 
ered body  temperature. 

Idiopathic  Atrophy  of 
the  Skin. — Idiopathic  atro- 
phy of  the  skin  is  an  exceed- 
ingly rare  disease,  and  the  etiology  is  obscure.  Sometimes  excessive  cold 
or  heat,  nervous  influences,  etc.,  api^ear  to  be  the  cause.  The  atrophic  areas 
of  skin  slowly  increase  in  circumference,  and  eventually  lead  to  corre- 
sponding disfigurements.  As  yet  it  has  been  impossible  to  find  a  success- 
ful treatment. 


Fig.  872. — Ichthyosis  (Byrom  Bramwell). 


544    INJURIES  AND  SURGICAL  DISEASES  OF   THE  SOFT   PARTS. 

Dermatolysis.— Ill  the  so-called  dermatolysis  (Tilbury,  Fox),  the  skin, 
without  apparent  change  in  structure,  becomes  too  abundant  and  loose,  giv- 
ing rise  to  folds.  The  faces  of  youthful  individuals  may  thus  assume  an 
aged  expression.  The  elasticity  of  the  skin  is  sometimes  very  marked  ;  the 
skin  of  tlie  chest  may,  for  example,  be  drawn  up  as  far  as  the  eyes. 

Ichthyosis  (from  Ix&vs,  fish)  is  usually  a  congenital,  scale-like  thickening 
of  the  epidermis  involving  generally  the  entire  body  (Fig.  372). 

Hystricismus  (from  Zarpi^,  swine's  bristle)  is  also  a  congenital  disease 
and  consists  in  the  formation  of  growths  on  the  skin  resembling  thorns,  and 
results  from  hypertrophy  of  the  papilhii  and  epidermis. 

Mycosis  fimgoides  (/xv^j??,  fungus,  sponge,  elBos,  shape,  form)  is  a  very 
interesting  disease  which  begins  by  the  formation  of  spots  either  isolated  or 
confluent,  which  resemble  sometimes  urticaria  and  sometimes  psoriasis  or 
eczema.  Fungous  tumours  of  semi-soft  consistency  are  then  gradually 
formed  in  various  places  on  the  body  ;  these  break  down  and  disappear  com- 
pletely, leaving  behind  brownish  or  greenish  crusts.  With  the  repeated  for- 
mation of  new  tumours  the  patient  gradually  succumbs  to  an  increasing 
cachexia,  accompanied  usually  by  a  profuse  diarrhoea.  The  new  growths 
belong  probably  to  the  granulation  tumours.  It  is  possibly  an  infectious 
disease  caused  by  micro-organisms.     The  treatment  is  symptomatic. 

Emphysema — i.  e.,  a  collection  of  air  in  the  skin  and  subcutaneous  tis- 
sue— is  observed  most  frequently  after  injuries  of  the  larynx,  trachea,  and 
lungs.  There  can  be  felt  in  such  cases  characteristic  soft  crepitating  swell- 
ings. Emjihysema  may  gradually  spread  over  the  entire  body  (see  Regional 
Surgery). 

For  tumours  of  the  skin,  see  Tumours,  §§  125  to  130. 

§  94.  Inflammations  and  Surgical  Diseases  of  the  Mucous  Membranes. 

— Diseases  of  Mticous  Meinhranes  of  Surgical  Importance. — Brief 
mention  will  be  made  here  only  of  those  diseases  and  inflammations  of 
mucous  membranes  which  are  the  object  of  surgical  treatment.  We 
shall  discuss  injuries  in  Regional  Surgery.  As  a  general  rule,  wounds 
of  mucous  membrane,  if  strict  asepsis  is  observed,  heal  readily,  particu- 
larly under  the  use  of  iodoform. 

Acute  Inflammation. — Acute  inflammation  of  the  mucous  membranes 
occurs  as  an  acute  catarrh  or  acute  catarrhal  inflammation  which  is 
characterised  by  hyperemia,  cfidematous  swelling,  and  the  formation 
of  a  discharge  at  first  poor  in  cells  and  then  containing  large  quantities 
of  them.  Some  of  the  cells  are  extra  vasated  colourless  blood -corpuscles, 
and  others  desquamated  epithelium.  Not  infrequently  in  catarrh  there 
is  a  development  of  vesicles  and  superficial  losses  of  substances — catar- 
rhal ulcers.  The  causes  of  catarrhs  may  be  mechanical  or  chemical  in 
nature,  or,  what  is  most  common,  they  may  be  due,  in  the  main,  to 
micro-organisms,  as  is,  for  instance,  the  acute  catarrh  of  the  mucous 
membrane  of  the  genitals — gonorrhoea  (see  page  444).  Catarrhs  which 
occur  as  a  result  of  chemical  irritations  are  produced,  for  example,  by 


94.] 


DISEASES  OP  THE  MUCOUS   MEMBRANES. 


545 


Fig.  373. — Croupous  membrane  {B)  upon  a  mucous 
membrane  (iSch),  consisting  of  a  network  of 
fibrin  which  is  filled  with  leucocytes,     x  150. 


the  action  of  mercury  or  iodine  ;  many  individuals  are  very  susceptible 
to  these  two  substances.  The  acute  inflammations  which  follow  the 
use  of  mercury  and  attack  the 
cavity  of  the  mouth  (stomatitis 
mercurialis),  are  occasionally 
observed  during  the  treatment 
of  a  wound  with  bichloride,  or 
during  the  inunction  treatment 
of  syphilis,  etc.  (see  page  445). 
Mercurial  stomatitis  is  charac- 
terised by  a  swelling  of  the 
gums,  salivation,  swelling  of  the 
mucous  membrane  of  the  mouth 
at  various  points,  and  the  for- 
mation of  ulcers.  Mercurial  stomatitis,  as  we  shall  see,  is  best  pre- 
vented by  cautious  use  of  bichloride  in  the  treatment  of  wounds,  by 
paying  careful  attention  to  the  cleanliness  of  the  mouth,  by  stopping 
smoking  during  the  inunction  treatment,  etc.  The  treatment  of  the 
mercurial  stomatitis  itself  consists  in  gargling  with  chlorate  of  potash 

or  boric  acid.  This  complica- 
tion can  usually  be  speedily 
cured  by  superficial  cauterisa- 
tion of  the  ulcers  with  silver 
nitrate  or  copper  sulphate  in 
substance,  and  also  by  stopping 
^/-iKssr  •"^'«'»>^.'  the  bichloride  dressings  or  the 

^'^^^i^'M'uA*  B      inunctions. 

Cancrum  oris  or  noma  is 
a  severe  ulcerative  stomatitis, 
which  will  be  discussed  in  He- 
gional  Surgery,  with  the  other 
diseases  of  the  mucous  mem- 
branes in  the  facial  cavities,  the 
digestive  tract,  genito-urinary 
apparatus,  etc. 

Croupous  and  Diphtheritic 
Inflammation.  —  By  croup  and 
diphtheria  inflammatory  pro- 
cesses are  understood  which  are  for  the  moSt  part  identical  pathologi- 
cally and  clinically,  and  only  differ  in  degree.  Both  inflammations  are 
characterised  by  the  formation  of  an  inflammatory  product  consisting 
of  fibrin  and  cells,  which  is  slightly  adherent  to  the  surface  of  the 
38 


Fig.  374. — Section  through  the  uvula  in  diphtheri- 
tis  faucium  at  the  border  of  the  healthy  tissue  : 
A,  normal  epithelium  and  submucous  tissue; 
^,  the  connective  tissue  underneath  the  epithe- 
lium and  mucous  membrane  infiltrated  with 
fibrin,  leucocytes,  and  red  blood-corpuscles; 
Jf.  masses  of  micrococci,     x  120. 


540    INJURIES  AND  SURGICAL  DISEASES  OF   THE   SOFT   PARTS. 


mucous  membrane.  In  croup  (Fig.  373)  the  membrane  lies  ujxjii  the 
mucous  membrane,  while  in  diphtheria  the  exudate  is  also  found  in 
the  mucous  membrane,  and  the  latter  becomes  more  or  less  necrotic 
(Fio;.  374).  In  the  formation  of  this  pseudo-membrane,  according  to 
Baumgarten,  the  "•  fibrinoid ''  degeneration  of  the  epithelium  plays  an 
important  part  as  well  as  the  fibrinous  exudate.  In  croup  there  is  a 
fibrinoid  degeneration  of  the  epithelium  only,  but  in  diphtheria  this 
process  also  involves  the  connective  tissue.  The  local  death  of  tissue 
produced  by  the  diphtheritic  inflammation  is,  according  to  Cohnheira 
and  Weigert,  a  coagulation  necrosis — i.  e.,  a  death  of  the  tissues  and 

cells  due  to  the  coagulation  of  lymph 
which  permeates  the  affected  tissues  and 
penetrates  into  the  cells.  The  croupous 
and  dii^htheritic  membranes  come  away 
after  a  certain  length  of  time,  being  cast 
off  b}^  the  new  epithelium  which  is  pro- 
duced underneath  and  pushes  the  re- 
mains of  the  membrane  before  it ;  in 
severe  cases  the  membrane  comes  away 
in  toto.  In  extensive  croup  of  the 
bronchi  the  latter  are  filled,  in  severe 
cases,  with  a  fibrinous  exudate,  so  that 
there  is  marked  dyspnoea,  and  the  pa- 
tient coughs  up  branched  masses  of 
fibrin  corresponding  to  the  bronchi  (Fig. 
375).  Croup  can  be  excited  experimen- 
tally by  the  injection  of  liq.  ammonii 
caustici  into  the  trachea  of  a  rabbit,  the  animals  usually  dying  in  two 
to  three  to  four  days  ^vith  symptoms  of  asphyxia.  There  is  no  ana- 
tomical distinction  between  this  experimental  croup  and  epidemic  diph- 
theria (Middeldorpf,  Goldmann).  The  pharynx  and  trachea  are  most 
frequently  affected  by  the  croupous  and  diphtheritic  inflammation  ;  less 
often  the  mucous  membrane  of  the  bladder  and  intestine.  Diphtheria 
occasionally  occurs  in  the  skin,  starting,  for  example,  from  infection 
through  a  cutaneous  abrasion  or  wound,  especially  in  the  neighbour- 
hood of  mucous  membranes  such  as  that  of  the  female  genital  tract, 
the  rectum,  etc.  True  diphtheria  is  an  infectious  disease  which  is  pro- 
duced by  a  specific  bacillus  discovered  by  Lofiler,  and  is  to  be  carefully 
distinguished  from  all  other  pathological  processes  which  are  likewise 
accompanied  by  the  formation  of  croupous  or  diphtheritic  changes 
in  the  mucous  membranes  and  do  not  differ  anatomicalhj  from  true 
diphtheria  (so-called  pseudo-diphtheria).     By  temporarily  interrupting 


Fig.  375. — Branching  mass  of  fibrin  in 
bronchial  croup. 


§94.]  DISEASES   OP   THE   MUCOUS  MEMBRANES.  547 

the  circulation  of  blood  in  the  urinary  bladder  Heubner  excited  arti- 
ficially a  local  pseudo-diphtheria  of  this  description  which  was  not 
transmissible  to  animals  by  inoculation  like  true  diphtheria.  In  every 
case  of  suspected  diphtheria  a  bacteriological  examination  should  be 
made  for  the  detection  of  the  Loffler  bacillus.  In  true  diphtheria  there 
develops,  as  a  result  of  the  absorption  of  the  poisonous  products  of  the 
bacterial  metabolism,  a  febrile  systemic  intoxication  the  severity  of 
which  varies  greatly,  though  it  very  often  speedily  terminates  in  death, 
particularly  when  a  degeneration  of  the  muscles  of  the  heart  takes 
place.  Another  important  cause  of  death  consists  in  extension  of  the 
inflammation  to  the  lungs.  Among  further  sequelee  of  diphtheria, 
nephritis  (albuminuria)  and  paralyses  are  especially  prominent.  Bag- 
insky  has  observed  in  rare  cases  the  development  of  tetanic  symptoms 
(trismus  and  tetanus).  The  symptomatology  of  diphtheria  is  discussed 
in  Regional  Surgery.     See  also  "Wound  Diphtheria,  §  72. 

The  Etiology  of  Diphtheria— Ldffler's  Diphtheria  Bacillus.— Loffler  was 
the  first  to  prove  the  constant  presence  of  a  species  of  bacteria  in  human 
diphtheria ;  he  cultivated  it  artificially  and  inoculated  animals  with  it.  It 
was  impossible  to  excite  genuine  diphtheria  in  animals,  but  Loffler  was 
able  to  prove  that  the  bacteria  in  question  had  pronounced  poisonous 
properties.  Frankel  and  others  have  confirmed  Loffier's  statements,  and 
Roux  and  others  successfully  inoculated  animals  with  Loffier's  bacillus 
and  observed  the  symptoms  which  are  peculiar  to  human  diphtheria,  par- 
ticularly the  formation  of  local  diphtheritic  processes  and  the  paralyses 
which  follow  the  general  intoxication.  Upon  the  basis  of  these  facts,  we 
are  justified  in  the  belief  that  Loffier's  bacillus  is  the  actual  excitant  of 
diphtheria. 

The  diphtheria  bacilli  are  small  rods  about  as  long  as  tubercle  bacilli, 
though  almost  twice  as  thick,  of  a  plump  appearance,  and  generally  with 
rounded  ends  (Fig.  376).  They  vary,  however,  greatly  in  their  form,  the 
rods  having  frequently  a  club-shaped  thickening  at  the  end,  while  others 
are  in  process  of  division  into  several  pieces  by  transverse  segmentation 
Cmanifestations  of  involution).  The  bacilli  are  found  in  the  diphtheritic 
pseudo-membrane,  and  nowhere  else  in  the  body ;  consequently  the  severe 
constitutional  symptoms  of  diphtheria  are  caused  by  the  exceedingly  poison- 
ous products  of  their  metabolism.  Opinions  vary  as  regards  the  nature  of 
the  toxines  of  the  diphtheria  bacilli,  though  they  are  generally  considered 
to  be  albuminoid  bodies  belonging,  according  to  Brieger  and  Frankel,  to  the 
toxalbumens,  according  to  Roux  and  Yersin  to  the  diastases,  and  according 
to  Gamaleia  to  the  nuclein  compounds.  They  are  formed  either  by  the  de- 
composition of  the  albuminous  bodies  contained  in  the  nutritive  substances, 
or  the  microbes  develop  them  within  themselves  by  synthesis  of  simpler 
bodies  (Guinochet,  Strauss).  The  toxic  substances  of  the  diphtheria  bacilli 
are  marked  by  a  certain  instability  being  destroyed  by  heat  and  ferments 
(pepsin,  pancreatin),  and  passing  through  the  digestive  tract  without  causing 
any  disturbance  (Gamaleia).     The  diphtheritic  j)oison  is  decidedly  weakened 


548    INJURIES  AND  SURGICAL   DISEASES   OP  THE  SOFT   PARTS. 

by  antipyriiie  (Vianna).     Mixed  (septic)  infections  originate  from  the  pres- 
ence at  the  same  time  of  streptococci  and  staphylococci. 

The  bacilli  are  facultative  anaerobic,  and  incapable  of  movement;  they 
grow  at  temjjeratures  ranging  between  68°  and  104°  F.  upon  gelatine  or  other 
nutritive  medium,  which  must  always  be  made  slightly  alkaline,  and  esi^e- 
cially  well  upon  Loffler's  blood  serum  (three  parts  blood  serum  from  cattle 
or  sheep,  one  part  beef  bouillon,  one  per  cent,  peptone,  one  half  per  cent, 
common  salt,  one  per  cent,  grape  sugar)  and  upon  glycerine-agar.  On 
Lofiier's  blood  serum  a  thick,  glistening,  whitish  scum  forms  in  the  incubator 
at  a  temperature  of  98A°  F.  in  about  two  days.  On  glycerine-agar  at  the 
incubator  temperature,  flat,  greyish-white,  glistening  colonies,  with  smooth 
edges,  the  size  of  a  millet  seed,  develop  within  twenty-four  to  forty-eight 
hours  (Fig.  377).  On  agar  the  cultures  at  first  grow  slowly,  but  the  second 
generation  more  luxuriantly,  as  the  bacilli  have  then  become  accustomed  to 
the  nutritive  medium,  which  was  not  at  first  suited  to  them.     But  at  the 


'1    i.^\ 


\  ^  "V 

Fig.  .376. — Diphtheria   bacilli.     Culture   on  Fig.  377. — Diphtheria  bacilli.    Colony  on  asrar 

coagulated  blood  serum,     x  1,000.  twenty-four  hours  old  ;  unstained,     x  100'. 

same  time  they  suffer  a  loss  in  virulence.  When  stab  cultures  are  made  in 
gelatine,  small  w-hite  globular  colonies  develop  along  the  inoculated  line  of 
puncture.  On  gelatine  plates,  at  a  temperature  of  2'i°  to  24°  C.  (71°  to  75°  F.), 
the  colonies  remain  small  and  the  gelatine  is  not  liquefied.  The  bacillus 
grows  upon  potatoes,  provided  the  sui'face  is  made  alkaline ;  milk  is  also  an 
excellent  nutritive  medium.  At  temperatures  ranging  from  4.5°  to  .50°  C. 
(113°  to  122°  F.)  the  bacilli  perish.  Spore  formation  has  not  been  observed. 
The  bacilli  are  also  possessed  of  great  powers  of  resistance ;  they  wall  remain 
in  a  dried  pseudo-membrane  and  be  capable  of  development  after  the  lapse 
of  three  to  four  months.  Roux  and  Yersin  demonstrated  that  serum  cul- 
tures, under  ordinary  conditions,  retain  their  vitality  and  virulence  for  five 
months ;  and,  furthermore,  that  the  cultures  kept  entirely  shut  off  from  the 
action  of  air  and  light  still  possess  their  full  virulence  after  the  lapse  of 
thirteen  months. 

The  diphtheria  bacilli  can  be  best  stained  with  Loffler's  alkaline  methyl- 
blue  solution ;  they  do  not  stain  by  Gram's  method.     But,  according  to  the 


§94.]  DISEASES   OP   THE   MUCOUS   MEMBRANES.  549 

recent  investigations  of  Roux  and  Yersin,  the  latter  method  can  also  be 
easily  used.  The  virulent  diphtheria  bacilli  are  almost  never  found  in  the 
mucus  of  the  mouth  of  a  man  who  is  healthy  or  who  has  some  other  disease, 
but  Loffler  and  Hofmann  state  that  pseudo-diphtheria  bacilli  are  often  found 
which  are  very  similar  but  have  no  pathogenic  action,  and  are  to  be  regarded 
as  possibly  weakened  forms  of  the  diphtheria  bacilli. 

Transmission  of  Diphtheria  to  Animals.— Inoculations  in  animals  are 
often  unsuccessful ;  guinea-pigs,  rabbits,  doves,  and  chickens  are  particularly 
susceptible,  while  mice  and  rats  are  not  very  much  so.  In  guinea-pigs, 
doves,  etc.,  the  cultures  excite  pseudo-membranes  in  the  trachea,  and  some- 
times severe  constitutional  symptoms,  paralyses,  etc.  Guinea-pigs  are  the 
most  susceptible ;  within  a  few  days  after  subcutaneous  inoculation  they  die 
with  oedema,  pleuritic  effusions,  etc.,  but  the  bacilli  are  not  found  in  the 
internal  organs.  Filtered  cultures,  or  the  poisonous  albuminous  bodies 
(toxalbumens)  isolated  from  the  cultures  excite  severe  symptoms  of  intoxica- 
tion, which,  however,  take  a  long  time  to  cause  death. 

Artificially  Acquired  Immunity  from  Infection  by  Diphtheria.— Behring 
and  Kitasato  have  made  animals  artificially  immune  from  diphtheria  (1)  by 
the  use  of  cultures  sterilised  by  Frankel's  method ;  (2)  by  the  addition  of 
iodoform  to  the  cultures  ;  (3)  by  subcutaneous  and  intra-abdominal  injection 
of  the  pleuritic  exudate  which  frequently  forms  in  diphtheritic  animals  ;  (4) 
by  subcutaneous  injection  of  iodoform  very  soon  or  a  few  hours  after  the 
infection  with  diphtheria.  It  is  also  possible  to  give  animals  an  increased 
power  of  resistance  against  diphtheritic  infection  by  the  administration  of 
peroxide  of  hydrogen  for  a  few  days  before  the  infection.  By  inoculating 
guinea-pigs  with  sterilised  culture  fluids  heated  for  a  few  hours  to  between 
60°  and  70°  C.  (140°  and  168°  F.),  C.  Frankel  obtained  immunity  after  the 
lapse  of  fourteen  days.  Two  kinds  of  substances  are  found  in  the  culture 
fluids  of  diphtheria  bacilli,  viz.,  a  toxic  substance  which  is  destroyed  when 
heated  to  55°  to  60°  C.  (131°  to  140°  F.),  and  an  immunising  substance.  Ac- 
cording to  Behring  and  Kitasato,  the  animals  which  have  been  rendered  im- 
mune are  not  only  protected  from  infection  with  living  diphtheria  bacilli, 
but  also  from  the  injurious  effects  of  the  poisonous  products  of  their  metab- 
olism. Nevertheless,  the  immunity  may  be  again  lost  by  repeated  injec- 
tions of  considerable  amounts  of  poison,  especially  if  the  immunity  has  not 
been  sufficiently  firmly  established.  The  artificially  acquired  immunity  to 
diphtheritic  infection  depends  upon  changes  in  the  blood  serum  of  the  ani- 
mal— i.  e.,  upon  the  presence  of  specific  protective  substances  (antitoxines) 
which  act  only  upon  the  diphtheritic  poison  and  not  upon  other  poisons. 
The  blood  serum  of  animals  (horses)  rendered  immune  to  diphtheria  is  con- 
sequently used  in  the  form  of  hypodermic  injections  in  the  treatment  of 
diphtheria.  Since  the  introduction  of  this  antitoxine  treatment  of  diph- 
theria the  mortality  of  the  latter  has  diminished.  The  earlier  it  is  used  the 
more  efficient  is  its  action.  The  latter  consists  either  in  a  direct  influence 
upon  the  diphtheritic  poison  or  in  a  strengthening  of  the  curative  powers  of 
the  organism — in  other  words,  an  increase  in  its  power  of  resistance.  The 
antitoxic  serum  can  also  be  used  to  advantage  in  a  prophylactic  way  to  pro- 
tect those  in  the  vicinity  of  the  patient  from  infection.  This  immunising 
action  of  the  antitoxic  serum  may  last,  according  to  Heubner,  only  three 


550    INJURIES  AND  SURGICAL   DISEASES  OF  THE  SOFT   PARTS. 

weeks,  so  that  in  a  prolonged  epidemic  it  would  be  necessary  to  repeat  the 
injection  from  time  to  time. 

Spread  of  Diphtheria. — The  bacillus  of  diphtheria  varies  in  the  deg-ree  of 
its  virulency  at  diU'erent  times.  This  explains  why  the  course  of  diphtheria 
in  different  cases  and  in  different  epidemics  is  so  dissimilar.  Diphtheria 
spreads  by  contagion ;  the  membranes  which  ai-e  coughed  up,  the  sputa  and 
the  saliva,  are  the  most  common  sources  of  infection.  During  convalescence 
the  bacilli  remain  alive  in  the  mouth  for  about  three  weeks ;  in  a  dried  con- 
dition they  may  persist  in  thick  layers  for  three  to  four  months,  and  in  a 
half-dried  condition  for  seven  mouths.  Toys,  eating  and  drinking  utensils, 
kissing,  etc.,  sometimes  cause  the  spread  of  the  disease.  An  ectogenous  de- 
velopment of  diphtheria  bacilli  sometimes  takes  place  in  articles  of  food, 
such  as  milk.  The  individual  predisposition  to  diphtheria  decreases  very 
much  after  the  thirteenth  year.  A  pharyngeal  mucous  membrane  affected 
with  or  having  a  tendency'  to  catarrh  is  a  favourable  soil  for  the  lodgment 
of  the  diphtheria  bacillus.  To  prevent  the  starting  and  spread  of  diphtheria, 
the  patients  should  first  of  all  be  strictly  isolated  in  every  respect,  and  objects 
coming  in  contact  with  them  should  be  properly  disinfected.  Fui'thermore, 
the  healthy  individuals  living  with  the  patient  should  be  injected  with  anti- 
toxic serum. 

Other  Bacteria  Streptococci  and  Staphylococci  present  in  Diphtheria.— In 
addition  to  the  diphtheria  bacilli  there  are  very  frequently — in  fact  almost 
always — found  streptococci.  These  appear  to  have  no  bearing  upon  the 
diphtheria  as  such,  but  may  give  rise  to  general  septic  infection — mixed  in- 
fection (Beck,  Barbier,  etc.).  But,  according  to  Baginsky,  there  is  a  form  of 
diphtheria  which  clinically  is  like  true  diphtheria,  but  is  not  dangerous,  and 
terminates  in  recovery ;  in  this  Loffler's  bacillus  is  not  present,  and  Baginsky 
only  found  streptococci  and  staphylococci. 

The  Pseudo-Diphtheria  Bacillus. — In  addition  to  the  diphtheria  bacillus, 
whicli  is  the  excitant  of  true  diphtheria,  Loifier  and  others  have  described  a 
pseudo-diphtheria  bacillus  which  is  morphologically  and  biologically  slight- 
ly different  from  the  true  diphtheria  bacillus.  It  is  somewhat  shorter  and 
thicker,  grows  luxuriantly  at  a  temperature  of  20°  to  22°  C.  (68°  to  72°  F.) 
in  bouillon,  and  changes  the  reaction  of  bouillon  more  rapidly,  forms  upon 
serum  a  more  j^ellow  scum,  and  does  not  thrive  as  well  in  the  absence  of  air 
as  the  true  diphtheria  bacillus.  When  inoculated  in  animals,  local  manifes- 
tations are  sometimes  observed,  but  death  never  occurs  (Roux,  Yersin).  The 
pseudo-diphtheria  bacillus  is  found  in  the  mouths  of  healthy  individuals, 
and  in  simple  sore  thi'oats.  According  to  Roux  and  Yersin,  a  certain  rela- 
tionship exists  between  the  two  kinds  of  bacilli.  They  succeeded  in  perma- 
nently changing  very  virulent  true  diphtheria  bacilli,  by  the  action  for  sev- 
eral days  of  a  steady  stream  of  air,  to  such  an  extent  that  they  behaved  like 
pseudo-diphtheria  bacilli ;  and  on  the  other  hand,  by  simultaneous  inocula- 
tions with  erysipelas  cocci,  they  were  able  to  restore  to  the  weakened  diph- 
theria bacilli  their  full  virulence,  but  not  to  the  pseudo-diphtheria  bacilli. 
More  recent  investigations  make  it  seem  probable  that  the  two  bacilli,  the 
true  diphtheria  bacillus  and  the  pseudo-diphtheria  bacillus,  are  not  different 
micro-organisms,  but  belong  to  the  same  species  and  are  merely  of  different 
virulence  (Loffler,  Frankel,  Hofmann,  Roux.  and  others). 


§  95.]       IXFLAMMATIOXS   AXD  DISEASES   OF   BLOOD-VESSELS.  551 

§  95.  Inflammations  and  Diseases  of  Blood-vessels. — The  acute  inflam- 
mations of  the  arteries  and  veins — arteritis  and  phlebitis — have  been 
described  in  §  69  and  §  75  (pysemia) ;  and  the  various  changes  which 
thrombi  undergo,  including  the  cicatricial  closure  of  a  vessel,  the  so- 
called  organisation  of  a  thrombus,  were  discussed  in  §  61.  There  re- 
mains for  us  to  take  up  chronic  inflammations  of  the  walls  of  the  ves- 
sels, as  well  as  aneurisms  and  varicose  veins. 

Chronic  Inflammations  of  the  Walls  of  the  Vessels. — The  fatty,  amy- 
loid, and  hyaline  degenerative  changes  occurring  in  vessels  belong 
more  to  the  domain  of  pathological  anatomy,  but  hypertrophic  con- 
ditions in  the  arteries  have  also  a  surgical  importance.  The  develop- 
ment of  the  collateral  circulation  after  occlusion  of  a  vessel  or  the  for- 
mation of  an  aneurysma  racemosum  (see  Aneurisms)  depends  upon  a 
hyperplasia  of  all  the  arterial  coats.  Chronic  endarteritis  is  particu- 
larly important ;  it  consists  in  a  hypertrophy  of  the  intima  from  a 
circumscribed  or  more  diffuse  growth  of  connective  tissue.  In  this 
class  belong  endarteritis  obliterans,  endarteritis  deformans,  and  arterio- 
sclerosis or  atheroma.  These  chronic  inflammations  of  the  walls  of 
blood-vessels  with  thickening  and  hardening  of  the  same  occur  in  vari- 
ous diseased  conditions — e.  g.,  syphilis,  nervous  diseases,  diabetes,  alco- 
Jholism,  lead -poisoning  and  other  kinds  of  poisoning,  and  also  as  a  sign 
of  disturbance  of  nutrition  in  old  age.  Kodular  or  more  difEuse  thick- 
enings of  the  arteries  develop  from  inflammations  in  the  parts  sur- 
rounding the  arteries — in  other  words,  from  periarteritis.  Phleljitis 
hyperplastica  and  periphlebitis  chronica  are  much  rarer  than  chronic 
arteritis,  and  the  pathological  changes  are  not  by  any  means  so  pro- 
nounced. 

Endarteritis  Obliterans. — The  endarteritis  of  syphilis  was  first  accurately 
described  by  Heubner ;  it  occurs  either  independently  and  by  itself,  or  within 
a  focus  of  syphilitic  inflammation.  The  process  begins  with  a  cellular  infil- 
tration of  the  intima,  which  subsequently  changes  into  connective  tissue  ;  the 
media  remains  more  or  less  intact,  or  likewise  changes  into  fibrous  tissue. 
The  thickening  of  the  walls  of  the  vessels  in  syphilis  is  not  infrequently  very 
considerable,  and  the  lumen  of  the  arteries  may  not  only  be  naiTowed,  but 
even  completely  closed.  The  syphilitic  inflammation  also  occurs  in  the 
intima  of  the  veins.  As  Friedlander  in  particular  has  pointed  out,  there 
occurs  not  only  in  syphilis,  but  also  in  various  other  chronic  inflammatory 
conditions,  an  obliterating  endarteritis  from  proliferation  of  the  endothelium 
of  the  larger  arteries  as  well,  which,  when  it  affects  an  extremity,  may 
threaten  the  integrity  of  the  whole  limb.  Riedel  observed  gangrene  of  the 
leg  following  a  circumscribed  obliterating  endartei'itis  of  the  femoral  artery 
in  a  woman  thirty-six  years  of  age.  Circumscribed  or  more  diffuse  infiltra- 
tions of  the  walls  of  the  vessels  are  also  produced  by  tubercular  inflamma- 
tion. 


552    INJURIES  AND  SURGICAL  DISEASES  OF   THE  SOFT   PARTS. 


Congenital  stenosis  of  the  aorta  (Mox'gani,  Virchow,  Frantzel,  etc.)  is  a 
matter  of  nioi'e  consequence  to  the  physician. 

Sclerosis  or  Atheroma  of  the  Vessels.— Atheroma  of  the  arteries  (arterio- 
sclerosis) is  mainly  a  disease  of  old  age,  and  is  particularly  apt  to  follow  the 
habitual  use  of  alcohol.  It  consists  of  thickenings  of  the  intima,  which  occur 
in  patches.  The  thickened  parts,  especially  at  the  outset,  are  soft  and  jelly- 
like, or  dense  and  fibrous,  or  more  cartilaginous  in  character.  The  athe- 
romatous patches  often  become  calcified,  or  the  tissue  may  break  down  and 
give  rise  to  losses  of  substance  (atheromatous  ulceration).  Atheroma  may 
occur  in  all  parts  of  the  arterial  system,  from  the  valves  of  the  aorta  to  the 
smallest  arteries,  and  is  sometimes  developed  to  an  extreme  degree.  Athe- 
roma of  the  veins  is  more  rare,  and  never  of  as  high  a  grade.  It  is  essentially 
an  endarteritis  which  begins  with  inflammatory  infiltration,  and  leads  to  a 
new  formation  of  connective  tissue.  This  is  followed  by  retrogressive  changes 
(fatty  degeneration,  necrosis,  calcification).  As  a  result  of  arterio-sclerosis 
there  occur  a  thickening,  narrowing,  or  occlusion  of  the  vessels,  with  second- 
ary disturbances,  and  finally  necrosis  of  the  parts  supplied  by  the  affected  ves-* 
sel,  as  in  senile  gangrene  (see  Regional  Surgery).  On  the  other  hand,  dilata- 
tion and  rupture  of  the  walls  of  the  artery  occur  if  the  media  also  degenerates 
and  loses  its  power  of  resistance.  Neurotic  angiosclerosis  is  a  special  form 
resulting  from  injuries  and  diseases  of  the  nervous  system  (tabes,  progressive 
paralysis,  neuritis,  syringomyelia,  etc.)  and  occurring  at  any  age.  It  leads 
to  thickening  of  the  walls  of  arteries  and  veins,  at  first  from  hj'pei'trophy 
of  the  media  and  later  of  the  intima,  followed  by  marked  narrowing  of  the 
vessels  and  cori'esponding  disturbances  of  nutrition  or  necrosis  of  the  tissues. 

Aneurisms. — By  aneurism  is  understood  a  dilatation  of  an  artery 
filled  with  flowing  blood.     The  dilatation  is  either  limited  to  a  certain 

portion  of  the  artery  (Fig. 
378),  or  there  is  an  expan- 
sion of  a  whole  group  of 
arterial  branches  and  of 
capillaries  with  a  simultane- 
ous hypertrophy  of  their 
walls  (Fig.  383).  The  lat- 
ter form  of  aneurism  is 
called  aneurysma  racemo- 
sum  or  anastomoticum. 

Aneurisms  originate  ei- 
ther from  injuries  or  from 
gradual  dilatation  of  the  ves- 
sel as  a  result  of  disease  of 
its  wall,  especially  chronic 
endarteritis  (atheromatous, 
syphilitic  endarteritis),  and  periarteritis  with  secondary  atrophy  of  the 
wall,  particularly  the  media.     Kohler  saw  a  large  axillary  aneurism 


Fig.  378. — Various  forms  of  aneurysms :  a,  cylindrical ; 
J,  spindle-shaped  ;  c,  sacculated  aneurism. 


§95.]       INFLAMMATIONS  AND  DISEASES  OF  BLOOD-VESSELS.  553 


Fig.  379. — Arterio-venous  aneurism  (A)  at  the  bend  of  the  elbow, 
resultintr  from  a  venesection  (Bell).  The  aneurismal  sac  A  is 
cut  open  ( Froriep). 


wliicli  was  caused  by  an  echinococcus  in  the  sheath  of  the  artery.  All 
primary  and  secondary  diseases  of  the  walls  of  the  vessels  by  which 
the  strength  and 
elasticity  of  the 
walls  are  dimin- 
ished may  give  rise 
to  the  formation 
of  an  aneurism. 
According  to  the 
views  of  Koster 
and  Krafft,  true 
aneurisms  origi- 
nate mainly  from 
inflammatory  processes  in  the  media ;  but  Recklinghausen,  JVIanchot, 
and  others  insist  chiefly  upon  the  presence  of  primary  ruptures  of  the 
media  due  to  some  traumatism,  and  a  marked  elevation  of  the  blood 
pressure  following,  for  example,  some  violent  exertion ;  by  these  in- 
jurious influences  the  powers  of  resistance  possessed  by  the  arterial 
walls  are  lessened.  An  embolus  lodging  in  a  branch  of  an  artery  may 
also  cause  an  aneurism — for  example,  calcified  endocarditic  vegeta- 
tions may  bore  their  way  into  the  wall  of  an  artery,  possibly  in 
the  brain,  and  erode  it,  causing  it 
to  give  way  and  dilate — embolic 
aneurisms  (Ponfick).  Moreover, 
aneurisms  may  occasionally  result 
from  emboli  of  a  suppurative  or 
septic   character   with    secondary 


Fig.  880. — Arterio-venous  aneurism  :  a,  brach^- 
ial  artery ;  6,  vena  mediana.  The  sac  of 
the  aneurism  which  communicates  with 
the  artery  and  vein  is  cut  open  (Dorsey). 


Fig.  381. — Arterio-venous  aneurism  of  the 
temporal  artery  and  vein  following  an 
incised  wound  received  twenty-five  years 
before  (Czerny). 


necrosis  of  the  wall  of  the  vessel  following  endarteritis  or  periarteritis 
(Buday,  etc.).  All  aneurisms  developing  from  a  gradual  dilatation  of 
all  the  coats  of  the  vessel  used  to  be  called  true  aneurisms  (aneurysma 


554    INJURIES   Ax\D  SURGICAL   DISEASES   OF  THE  SOFT   PARTS. 


vera),  in  contradistinction  to  the  traumatic  aneurisms,  which  were  desig- 
nated as  false  (aneurvsma  spuria),  from  the  fact  that  their  walls  do  not 
consist  of  all  three  arterial  coats.     This  distinction  is  an  artificial  one 

and  incorrect.  Traumatic  aneurisms 
from  a  punctured  injury,  for  exam- 
ple, are  brought  about  by  a  gradual 
yielding  of  the  thrombus  in  the  wall 
of  the  vessel  and  of  the  surrounding 
cellular  connective  tissue,  as  a  result 
of  the  intra-arterial  pressure.  A  sac 
thus  finally  develops,  the  walls  of 
which  are  made  up  of  the  outermost 
layers  of  the  thrombus,  the  surround- 
ing soft  parts,  and  new-formed  con- 
nective tissue.  In  the  so-called  true 
aneurism  the  vessel  dilates  very  grad- 
ually, as  a  result  of  chronic  endarte- 
ritis, and  according  as  the  latter  in- 
volves the  entire  circumference  of  the 
artery  or  only  a  portion  of  it,  a  cy- 
lindrical (aneurysma  cylindricum)  or 
spindle-shaped  (aneurysma  fusiforme) 
or  sacculated  (aneurysma  sacciforme) 
aneurism  develops  (Fig.  378).  Of 
course,  there  are  many  transitions  be- 
tween each  of  these  different  forms. 

Occasionally  an  aneurism  comnm- 
nicates  with  an  adjoining  vein,  as  was 
formerly  not  uncommon  after  phle- 
botomy, in  consequence  of  simultane- 
ous injury  to  the  brachial  artery  at 
the  elbow.  An  aneurism  of  this  de- 
scription Yirchow  calls  an  arterio- 
venous aneurism.  This  term  is  better  than  varicose  aneurism  or  aneu- 
rismal  varix.  The  arterio-venous  aneurism  takes  the  form  either  of  a 
circumscribed,  sacculated  tumour,  as  illustrated  in  Figs.  379  and  380, 
or,  as  a  result  of  the  communication  between  the  artery  and  vein,  there 
Occur  marked  disturbances  in  the  circulation,  with  pulsating  dilatations 
of  the  distant  branches  of  both  artery  and  vein  (Figs.  381,  382).  If 
pressure  is  applied  to  the  point  of  communication  between  the  artery 
and  vein,  the  pulsation  in  the  dilated  and  tortuous  vessels  ceases  and 
they  collapse.     In  the  extremities  the  arterio-venous  aneurism,  as  a 


Fig.  882. — Arterio-venous  aneurism  of  the 
left  liauiA  and  forearm  of  a  man  forty- 
five  years  old,  which  had  developed 
gradually  after  a  bite  on  the  hand  re- 
ceived in  his  seventh  year.  iSTumer- 
ous  sacculated  aneurisms  on  the  flexor 
side  ( £),  and  very  marked  varicose  en- 
largement of  the' veins  on  the  extensor 
side  (A). 


95.]        INFLAMMATIONS  AND   DISEASES   OF   BLOOD-VESSELS.  555 


result  of  the  communication  between  the  artery  and  vein,  leads  to  cir- 
culatory disturbances  throughout  the  entire  limb,  and  to  numerous 
small  aneurisms  and  dilatations  of  the  veins  (varices),  as  in  a  case 
reported  by  Stromeyer  and  Krause  (see  Fig.  382). 

According  to  Bramann,  of  one  hundred  and  fifty-nine  cases  of 
arterio- venous  aneurism,  one  hundred  and  eight  were  due  to  an  injury, 
fifty-six  following  phlebotomy,  twenty-nine  gunshot  wounds,  five  con- 
tusions which  caused  no  internal  wound,  and  nine  were  spontaneous. 
In  only  four  instances  was  an  arterio-venous  aneurism  congenital. 
An  arterio-venous  aneurism  may  develop  spontaneously  from  a  true 
aneurism,  which  becomes  gradually  adherent  to  the  vein.  The  latter 
becomes  obliterated  at  the  point  of  contact,  or  the  aneurism  ruptures, 
into  the  open  vein. 

Cirsoid  or  Racemose  Aneurism. — In  cirsoid  or  racemose  aneurism 
there  is  a  dilatation,  tortuosity,  and  thickening  of  the  artery  throughout 
its  entire  distribution,  form- 
ing a  convoluted  mass  of  en- 
larged arteries  (Fig.  383).  The 
racemose  aneurism  occurs  es- 
pecially upon  the  scalp,  is  for 
the  most  part  of  congenital 
origin,  and  belongs  more  to 
the  true  tumours,  and  hence 
the  term  racemose  angioma 
is  more  appropriate.  Cirsoid 
aneurism  is  rarely  acquired,  in 
which  case  it  may  result  from 
some  mechanical  injury.  A 
distinction  used  to  be  made  be- 
tween cirsoid  aneurism  (varix 
arterialis)  and  the  anastomotic 
aneurism  (angioma  arterial 
racemosum,  tumor  vasculosus 
arterialis).  The  former  was 
said  to  result  more  from  a  dif- 
fuse dilatation  of  the  arterial 
branches,  and  eventually  of 
the  capillaries  and  veins ;  while 

the  latter  was  said  to  be  made  up  of  newly  formed  dilated  and  length- 
ened arterial  branches,  resembling  more  closely  a  tumour.  But  both 
forms  merge  into  one  another  to  such  an  extent  that  it  is  impos- 
sible to  make  any  distinction.     An  analogous  tumour  formation,  the 


Fig.  383. — Cirsoid  aneurism  of  the  right  and  left 
angular  and  frontal  arteries  of  a  man  twenty 
years  old  (  Bruns).  Ligation  of  the  riarht  exter- 
nal carotid  and  the  left  common  carotid.  Death 
from  cerebral  embolus. 


55G     INJURIES  AND   SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

so-called  jjlexiforin  neuroma  (see  Tumours  of  jSTerves),  occurs  in  the 
nerves. 

Dissecting  Aneurism  (aneurvsma  dissecans)  is  a  particular  kind  of 
traumatic  aneurism  resulting  from  rupture  of  the  intima  and  media 
with  preservation  of  the  adventitia.  It  occurs  especially  in  the  aorta 
and  small  cerebral  arteries.  The  blood  escapes  between  the  media  and 
adventitia  and  lifts  one  from  the  other. 

Occurrence  of  Aneurisms. — As  regards  the  occurrence  of  aneurisms^ 
they  are  most  common  in  the  thoracic  aorta  (the  ascending  and  ti'ans- 
verse  portions),  appearing  next  in  order  of  frequency  in  the  popliteal, 
carotid,  subclavian,  innominate,  axillary  artery,  etc.  According  to  Liit- 
tich,  out  of  one  hundred  and  ninety-six  cases,  one  hundred  and  sixty- 
one  were  observed  in  men  and  only  thirty-four  in  women.  Aneurisms 
are  comparatively  common  in  England,  particularly  in  the  English 
army.  The  cirsoid  aneurism  is  observed  most  frequently  in  the  com- 
mon iliac  and  on  the  scalp.  Of  aneurisms  involving  the  small  arter- 
ies, those  in  the  brain,  the  lungs,  and  the  heart  are  especially  impor- 
tant. As  regards  the  occurrence  of  aneurisms  in  bone  the  views  of 
different  authorities  are  divided.  If  they  occur  at  all  they  are  very 
rare.  In  the  majority  of  cases  of  so-called  bone  aneurism  we  have 
to  deal  with  a  very  vascular  sarcoma,  containing  sometimes  but  very 
little  sarcomatous  tissue. 

The  Symptoms  and  Course  of  Aneurisms. — The  most  important  symp- 
toms of  an  aneurism  are  brought  about  by  the  blood  flowing  into  the 
sac,  and  consist  in  the  presence  of  pulsation  and  a  friction  sound.  If 
a  hand  is  placed  upon  the  tumour  it  will  be  felt  to  enlarge  synchro- 
nously with  the  apex  beat.  By  palpation  and  auscultation  the  friction 
sound  can  also  be  made  out ;  it  is  caused  by  the  blood  rubbing  against 
the  inner  wall  of  the  sac.  As  regards  diagnosis,  a  careful  distinction 
must  be  made  between  the  actual,  true  pulsation  of  an  aneurism  and 
the  communicated  pulsation  which  results,  for  example,  from  a  tumour 
or  an  abscess  being  lifted  by  an  underlying  large  artery.  If  the  pulsa- 
tion is  communicated,  there  is  usually  only  a  rise  and  fall  in  one  direc- 
tion, and  the  tumour  does  not  expand  equally  in  all  directions,  as  is  the 
case  in  the  true  pulsation  of  an  aneurism.  But  the  pulsation  of  aneu- 
risms is  not  always  plain,  it  being  very  slight,  for  example,  in  those 
with  thick  walls.  If  the  afferent  artery  of  an  aneurism  is  compressed 
the  pulsation  and  friction  sound  cease.  Mention  should  be  made  of  the 
fact,  which  is  of  diagnostic  importance,  that  very  vascular  sarcomata 
of  bone,  for  instance,  also  pulsate. 

When  an  aneurism  has  once  formed,  the  local  dilatation  of  the 
lumen  of  the  artery  never  returns  to  the  normal  again,  but,  on  the 


§95.]        INFLAMMATIONS  AND  DISEASES   OF  BLOOD-VESSELS.         557 

contrary,  it  constantly  increases,  and  in  addition  the  wall  of  the  vessel 
becomes  steadily  thinner,  and  finally  the  sac  bursts,  leading  to  fatal 
haemorrhage,  especially  in  aneurisms  of  the  aorta,  the  brain  and  lungs, 
etc.  As  a  result  of  the  increasing  enlargement  of  the  sac,  the  sur- 
rounding parts  are  proportionately  displaced  and  the  bones  are  grad- 
ually more  or  less  eroded — for  example,  the  sternum,  the  vertebree,  and 
ribs,  in  aneurisms  of  the  aorta.  Pressure  upon  adjoining  nerves  gives 
rise  to  corresponding  symptoms  (pain,  paralysis).  The  skin  resists 
comparatively  the  longest  time,  but  it  also  may  be  broken  through, 
causing  sudden  death  from  haemorrhage. 

Spontaneous  cure  of  an  aneurism  by  filling  of  the  sac  with  a 
thrombus  and  by  change  of  the  latter  into  cicatricial  tissue  may  occur 
in  the  case  of  smaller  aneurisms  and  also  in  large  sacculated  ones. 
The  thrombi  originate  from  the  slowing  of  the  current  and  the  patho- 
logical changes  in  the  wall  of  the  aneurism. 

Extensive  thrombi  with  many  layers  also  develop  in  larger  aneu- 
risms, but  in  these  cases  complete  obliteration  of  the  aneurismal  sac 
by  cicatricial  connective  tissue  does  not  take  place.  The  thrombus 
formation  sometimes  increases  to  such  an  extent  that  the  circulation  is 
interrupted,  and  gangrene,  possibly  of  the  entire  extremity,  takes  place. 
Occasionally  the  thrombi  soften  and  break  down,  giving  rise  to  embolic 
processes,  or  the  thrombi  may  become  calcified. 

Diagnosis  of  Aneurisms.— From  what  has  been  said,  it  follows  that  the 
diagnosis  of  aneurism  is  not  difficult  as  long  as  we  have  to  deal  with  cases 
v^rhich  are  accessible  to  careful  examination.  As  regards  diagnosis,  the 
above-described  true  pulsation  and  the  friction  sound,  as  well  as  their  disap- 
pearance after  compression  of  the  afferent  artery,  are  the  most  important 
symptoms.  Nevertheless  good  surgeons  have  made  errors  and  taken  aneu- 
risms for  abscesses,  particularly  in  cases  where  there  are  manifestations  of 
inflammation,  swelling  of  the  soft  parts  around  the  aneurism,  etc.  If  this 
mistake  in  diagnosis  should  occur,  and  the  aneurism  be  incised,  resulting  in 
a  gush  of  blood,  the  incision  should  be  immediately  closed  by  placing  the 
hand  upon  it,  the  afferent  artery  compressed,  Esmarchs  rubber  tourniquet 
applied,  and  the  main  afferent  artery  immediately  ligated  in  its  continuity. 

On  the  other  hand,  it  may  happen  that  an  aneurism  is  supposed  to  be 
present,  while  as  a  matter  of  fact  we  have  to  deal  with  a  very  vascular 
tumour.  But  from  what  has  been  said  it  should  be  an  easy  matter  to  make 
the  correct  diagnosis  in  such  cases. 

Prognosis  of  Aneurisms. — The  prognosis  of  aneurisms  varies  greatly, 
according  to  their  location.  In  general,  the  prognosis,  as  far  as  spontaneous 
cure  is  concerned,  is  unfavourable,  as  this  termination  is  only  jjossible  in 
small  arteries  by  the  organisation  of  the  thrombi,  calcification,  etc.  In  large 
aneurisms  the  sac  constantly  increases  in  size,  and  there  is  nothing  to  do 
but  check  the  enlargement  of  the  aneurism  by  proper  local  treatment,  and 
possibly  to  extirpate  it. 


558    INJURIES  AND  SURGICAL   DISEASES  OF   THE   SOFT   PARTS. 

Treatment  of  Aneurisms. — Mention  niaj  be  made  iirst  of  the  opera- 
tive treatment  of  aneurisms.  The  oldest  method  of  operative  treat- 
ment is  that  of  Antjllus.  It  consists  in  splitting  open  and  extirpating 
the  sac  after  previously  performing  central  and  peripheral  ligation  of 
the  main  trunk  of  the  artery  and  any  branches  which  may  be  given 
off  from  the  aneurism.  The  aneurism  is  exposed  with  the  aid  of 
Esmarch's  artificial  ischgemia  and  opened  by  incision.  After  removing 
the  clot  from  the  sac  a  probe  is  passed  into  the  afferent  and  efferent 
ends  of  the  artery,  and  both  are  closed  by  a  ligature.  After  this  all 
branches  given  off  at  any  point  from  the  wall  of  the  sac  must  be  tied. 
The  aneurism  itself  can  then  be  extirpated,  or,  when  this  is  too  diffi- 
cult, a  portion  of  the  sac  may  be  left  behind.  The  performance  of 
this  operation  may  present  great  difficulties,  in  the  first  j^lace,  on 
account  of  the  numerous  branches  which  spring  from  the  wall  of  the 
sac,  and  then  because  the  aneurism  may  so  obscure  the  central  and 
peripheral  ends  of  the  artery  that  it  may  be  very  difficult  to  find  and 
ligate  them.  Other  methods  of  operative  treatment  for  aneurism  con- 
sist in  the  ligation  of  the  artery  on  the  central  or  peripheral  side  of  the 
aneurism.  The  central  ligation  of  the  afferent  arterial  trunk  is  either 
performed  close  above  the  aneurism  (Anel),  or  at  some  distance  from 
the  latter  at  the  so-called  place  of  election,  where  the  artery  is  easily 
accessible  (Hunter).  Ligation  of  the  artei'y  on  the  peripheral  side  of 
the  aneurism  has  been  recommended  particularly  by  Brasdor,  "War- 
drop,  and  Desault.  The  formation  of  a  thrombus  in  the  sac,  and 
thus  its  diminution  in  size  by  the  development  of  cicatricial  tissue, 
are  said  to  be  favoured  by  all  these  methods.  Their  success  is  uncer- 
tain, and,  particularly  after  ligation  of  the  afferent  artery,  gangrene 
has  been  observed  of  varying  extent  in  the  region  supplied  by  the 
artery.  Ligation  of  the  efferent  artery  is  especially  to  be  recommended 
when  ligation  of  the  afferent  vessel  is  impossible  or  too  difficult ;  thus, 
in  aneurism  of  the  innominate,  for  examj^le,  one  would  ligate  the 
carotid  and  subclavian  arteries.  The  best  though  at  the  same  time  the 
most  difficult  method  is  that  of  Antyllus.  The  next,  as  far  as  the 
certainty  of  its  effect  is  concerned,  is  the  ligation  of  the  afferent  arterial 
trunk  close  above  the  aneurism,  while  ligation  of  the  efferent  artery 
close  below  the  aneurism  is  the  most  uncertain  procedure.  After 
ligation  of  the  afferent  artery  at  the  place  of  election  in  Hunter's 
method,  recurrence,  as  a  general  thing,  easily  takes  place ;  never- 
theless this  method  is  of  value  for  the  reason  that  often  in  the  neigh- 
bourhood of  the  aneurism  the  artery  is  the  seat  of  atheromatous 
disease,  which  makes  ligation  impossible. 

Of  the  other  methods  of  treatment  we  should  mention,  in  the  first 


§  95.]       INFLAMMATIONS  AND  DISEASES   OF  BLOOD-VESSELS.  559 

place,  digital  and  instrumental  compression  of  the  afferent  artery^ 
which  is  particularly  adapted  for  aneurisms  upon  the  extremities. 
This,  also,  is  for  the  purpose  of  exciting  a  coagulation  in  the  aneu- 
rismal  sac.  The  procedure  is  entirely  devoid  of  danger,  but  it  is 
often  so  painful  that  the  patient  cannot  endure  it  long  enough. 
Sometimes  even  gangrene  of  the  skin  may  occur  at  the  point 
where  the  pressure  is  applied.  The  procedure  must  as  a  general  thing 
be  continued  for  several  days,  and  it  is  best  for  the  compression  to 
be  kept  the  same  for  several  hours.  The  compression-treatment  is 
adapted  particularly  to  recent  traumatic  aneurisms,  and  less  so  to  true 
aneurisms  where  there  is  atheromatous  degeneration.  It  is  less  dan- 
gerous than  the  operative  treatment.  Erichsen  found  that  in  fifty  per 
cent  of  the  cases  of  ligation  poor  results  followed,  of  which  twenty- 
five  per  cent  were  due  to  gangrene.  The  least  dangerous  and  the 
surest  method  of  employing  compression  is  digital  compression,  from 
which  Barwell  found  only  6.8  per  cent  of  deaths  or  amputations  in 
consequence  of  gangrene.  These  good  results  are  probably  explaina- 
ble by  the  fact  that  in  digital  compression  the  thrombus  probably 
remains  permeable  for  the  blood-stream.  There  must  be  several  per- 
sons who  can  relieve  one  another  in  performing  digital  compression. 
The  main  afferent  artery  is  compressed  at  a  point  central  to  the 
aneurism  for  a  variable  length  of  time  until  the  pulsation  in  the  an- 
eurism has  stopped.  In  some  cases  the  pulsation  stops  after  two  to 
three  hours'  compression,  but  at  other  times  it  has  to  be  continued  for 
several  days — preferably  with  free  intervals.  Special  pads,  Esmarch's 
elastic  bandage,  or  some  simple  substitute,  such  as  a  crutch  or  a 
broomstick,  have  been  recommended  for  carrying  out  instrumental 
compression.  Forced  flexion  of  the  extremity  has  also  been  used  in 
place  of  instruments  (see  Fig.  96).  Compression  by  means  of  elastic 
bandages  can  be  employed  as  follows  :  The  extremity  is  first  enveloped 
by  an  elastic  bandage  from  the  periphery  to  the  vicinity  of  the  an- 
eurism ;  an  elastic  bandage  is  then  tied  about  the  extremity  just  above 
the  aneurism,  and  the  bandage  below  removed  ;  in  about  an  hour  and  a 
half  the  upper  bandage  is  removed.  This  elastic  compression  may  then 
be  followed  by  several  hours  of  digital  compression.  Pearce  Gould  rec- 
ommends the  administration  of  dry  albuminous  food  and  large  doses 
of  iodide  of  potassium  before  using  the  elastic  compression,  in  order 
to  increase  the  coagulability  of  the  blood. 

The  other  methods  of  treating  aneurism  consist  in  exciting  a 
coagulation  of  the  blood  in  the  aneurismal  sac  by  chemical  means — as 
by  the  injection  of  ergotin,  liq.  ferri  sesquichlorat.,  alcohol,  etc. — or 
by  foreign  bodies  (catgut,  silver,  steel,  or  copper  wire,  horse-hair,  lami- 


560    INJURIES   AND  SURGICAL   DISEASES   OF   THE   SOFT   PARTS. 

naria),  bj  acupuncture,  bv  electropuncture  and  by  the  galvanic  current 
(cathode  on  the  aneurism).  I  consider  any  treatment  by  injection 
dangerous,  and,  consequently,  not  to  be  recommended ;  especially  after 
the  injection  of  liq.  ferri  sesquichlorat.,  extensive  clotting  and  speedy 
death  from  pulmonary  and  cerebral  emboli  have  taken  place.  As 
regards  the  results  obtained  by  the  introduction  of  steel  or  copper  wire 
(filipuncture)  into  large  aneurisms,  as  Moore  does  in  the  case  of  aortic 
aneurisms,  the  recently  published  statistics  of  Yerneuil  are  vei*y  un- 
favourable. Of  thirty-four  cases  treated  in  this  way,  only  two  were 
cured,  and  thirty  died  comparatively  soon  after  the  operation.  Phil- 
hppe  obtained  satisfactory  results  in  dogs  by  the  introduction  of  silver 
or  copper  wire,  horse-hair,  laminaria,  etc.,  into  the  femoral  or  carotid 
artery.  I  have  obtained  very  remarkable  results  in  aortic  aneurisms 
by  means  of  galvano-puncture,  the  technique  of  which  is  described  on 
page  81,  and  also  in  the  Regional  Surgery. 

The  best  treatment  for  cirsoid  aneurism  and  for  arterio-venous 
aneurism  is  extirpation,  followed  by  careful  arrest  of  all  bleeding  by 
ligation  of  the  afferent  and  efferent  vessels.  In  cirsoid  aneurism  liga- 
tion of  the  main  afferent  artery  is  also  to  be  recommended  ;  or  igni- 
puncture  may  be  performed  \vith  the  galvano-cautery  or  with  the  fine 
point  of  the  Paquelin  instrument. 

The  treatment  of  ordinary  aneurisms  of  course  varies  greatly  with 
their  location.  In  general  it  follows,  from  what  has  been  said,  that, 
whenever  it  is  possil)le,  compression  should  be  tried  first,  alternating 
elastic  bandaging  with  digital  compression  or  compression  by  means  of 
a  stick.  If  this  compression  treatment  is  borne  it  can  be  continued 
for  a  long  time.  Not  infrequently  compression  proves  successful  after 
the  lapse  of  months.  If  compression  cannot  be  carried  out  or  is  not 
successful,  an  operation,  when  possible,  should  be  undertaken,  the  best 
beiiig  that  of  Antyllus,  or,  if  the  latter  cannot  be  used,  Anel's,  Hun- 
ter's, or  Brasdor's  operation  should  be  performed  in  the  manner 
described  above. 

Varices  or  Varicose  Veins. — By  varix  is  understood  a  dilatation  of  the 
wall  of  a  vein  (Fig.  384).  This  originates  for  the  most  part  from 
mechanical  interference  with  the  return  flow  through  the  veins,  and, 
consequently,  occurs  in  local  or  general  stasis,  such  as  that  due  to  the 
presence  of  tumours,  particularly  in  the  abdomen,  or  to  pregnancy  ;  or 
it  is  due  to  cardiac  disease,  obstruction  to  the  entrance  of  venous  blood 
into  the  heart,  etc.  The  greater  the  resistance,  the  greater  will  be  the 
pressure  under  which  the  blood  flows  in  the  veins,  and  so  much  the 
sooner  will  the  walls  of  the  veins  become  stretched.  Occasionally  an 
inherited  disposition  towards  varices  must  be  acknowledged.     In  pre- 


§  95.]       INFLAMMATIONS  AND  DISEASES  OF  BLOOD-VESSELS.         561 

disposed  individuals  with  flabby  veins,  comparatively  slight  causes  may 
suffice  to  excite  varices.  Thus  varices  are  produced  in  the  lower 
extremities,  for  example,  of  individuals  whose  occupation  compels  them 
to  stand  a  great  deal. 

Occurrence  of  Varicose  Veins. — As  regards  the  occurrence  of  varices 
they  are  particularly  apt  to  be  found  in  parts  of  the  body  where  the 
return  flow  of  blood  in  the  veins  is  rendered  difficult,  and  consequently 
they  are  common  in  the  lower  extremities,  at  the  anus 
(haemorrhoids),  in  the  scrotum,  and  in  the  spermatic 
cord  (varicocele).     Women  suffer  from  varices  more 
commonly  than  men,  probably,  in  the  main,  as  a  result 
of  pregnancy.     Their  frequency  also  varies  among 
the  different  races. 

The  anatomical  changes  in  varicose  veins  consist 
in  a  chronic  endophlebitis  and  periphlebitis  with  hy- 
pertrophy of  the  muscular  coat  at  the  beginning, 
while  in  the  mild  and  in  the  advanced  cases  this  coat 
is  atrophic.  i  -   / 

Symptoms  of  Varicose  Veins. — The   subcutaneous       fc^'^^     ' 
veins  and  also  the  deeper  veins  in  the  muscles  are         *'*-  *    '' 
found  dilated,  tortuous,  and  lengthened  over  an  area 
of  variable  size.     Blue,  sacculated,  tortuous  bands  and 
convolutions  are  seen,   varying  in  size, 
over  which  the  skin  is  usually  more  or 
less  thinned.     I^ot  infrequently,  as  a  re- 
sult of  rupture  of  these  varices  and  the 
overlying  skin,  secondary  haemorrhages 

,•,  ,  1'1'jii  i  Fig.  3S4. — Varicose  ulcer  of  the  leof  (a), 

take    place   which,  m    the    lower    extrem-  resulting  from  varicose  veins! 

ity,  for  instance,  may  cause  death  if  not 

promptly  arrested  ;  under  these  conditions  a  spontaneous  arrest  does 
not  easily  occur.  Sometimes  periphlebitic  inflammation  and  supj)ura- 
tion  originate  in  the  parts  surrounding  the  varices,  possibly  in  conjunc- 
tion with  an  eczema  or  ulcer  in  the  skin.  Thrombi  are  also  observed 
in  varices  as  a  result  of  retardation  of  the  blood  current  in  the  dilated 
vessels,  just  as  in  aneurismal  sacs.  They  may  or  may  not  become 
organised,  soften  and  break  dovm,  or  become  calcified.  If  they  become 
calcified,  the  so-called  vein  stones  or  phleboliths  result.  When  thrombi 
form,  the  dilated  veins  are  plainly  to  be  felt  as  firm,  hard  cords.  Sup- 
purative breaking  down  of  the  thrombi  is  observed,  for  example,  in 
conjunction  with  an  ulcer  of  the  ]eg  or  eczema  which  has  not  been 
treated  antiseptically.  In  this  condition  there  is  danger  of  the  develop- 
ment of  embolic  processes  and  pyaemia  from  the  carrying  off  of  the 
39 


562    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT   PARTS. 

suppurating  clots  into  the  general  circulation.  It  is  a  matter  of  great 
practical  importance  that  wherever  varices  exist  there  is  a  tendency 
towards  inliauimatory  processes,  with  increased  transudation  and  cellu- 
lar intiltration.  Hence  it  is  clear  why  the  development  of  vesicles  and 
eczemas  which  break  down,  and  ulcerate  are  so  common  upon  lower 
extremities  where  there  are  varices.  Should  a  small  injury  be  received, 
there  is,  for  the  same  reasons,  only  a  slight  tendency  towards  repair, 
and  an  ulcer  may  readily  result.  The  ulcers  of  the  leg,  which  are  so 
common,  are  usually  observed  in  conjunction  with  varicosities,  and  so 
are  correctly  designated  varicose  ulcers  of  the  leg  (Fig.  384).  In  such 
cases  there  usually  exists  a  pronounced  inflammatory  condition  in  the 
lower  extremity,  with  hyperplasia,  extensive  oedema,  and,  in  severe 
cases,  a  deforming  of  the  foot  and  leg  by  an  induration  resembling 
elephantiasis. 

The  diagnosis  and  prognosis  of  varices  may  be  inferred  from  what 
has  just  been  said. 

Treatment  of  Varicose  Veins. — The  treatment  of  varicose  veins  varies 
with  their  cause  and  location.  I  must  refer  the  reader  to  Regional 
Surgery  for  the  detailed  description  of  the  treatment  for  varices  of 
special  localities — such  as  the  leg,  the  rectum  (haemorrhoids),  etc. 
Only  the  following  brief  statements  can  be  given  here  :  In  the  first 
place,  varices  can  be  cured  by  operative  measures — such  as  extirpation 
after  previously  applying  a  catgut  ligature,  or  by  cauterisation  with  the 
galvano-  or  Paquelin  cautery,  as,  for  example,  in  the  case  of  haemor- 
rhoids. In  severe  cases  good  results  have  been  obtained  from  the 
removal  of  the  varices,  in  the  lower  extremity,  for  example,  by  the 
following  method  :  By  allowing  the  leg  to  hang  down  from  the  oper- 
ating table  the  varices  are  caused  to  become  prominent ;  thin  rubber 
tubing  is  tied  around  the  upper  third  of  the  thigh,  loosely  enough  not 
to  compress  the  artery.  The  skin  is  divided  by  a  longitudinal  incision 
along  the  entire  length  of  the  varicose  vein,  and  freed  on  both  sides  of 
the  incision.  The  proximal  portion  of  the  vein — generally  the  saphe- 
nous— is  secured  by  a  double  ligature,  and  the  vein,  with  its  ramifica- 
tions, is  removed  from  above  downwards,  ^vithout  using  the  edge  of  the 
knife.  The  branches  are  seized  by  artery  clamps  and  ligated.  Per- 
cutaneous ligation  ( Umstechung)  of  the  veins  has  also  been  recom- 
mended ;  a  catgut  ligature  is  carried  on  a  curved  needle  under  the 
vein  and  knotted  on  the  skin,  possibly  over  a  drainage  tube.  Even 
after  extirpation  of  the  varices  recurrences  are  rather  common.  In 
extensive  varices  involving,  for  example,  the  subclavian  vein  and  its 
branches,  I  can  recommend  a  very  simple  and  effective  method,  namely, 
ignipuncture — i.  e.,  puncturing  the  varicose  venous  trunks  with  the 


§  95.]        INFLAMMATIONS  AND   DISEASES   OF  BLOOD-VESSELS.         563 

galvano-cautery,  or  with  the  fine  point  of  the  Paquelin  cautery.  A 
protective  dressing  is  ordinarily  unnecessary,  or,  at  the  most,  only  for 
twenty-four  hours.  The  puncture  wounds  dry  and  are  covered  by 
small  scabs,  which  fall  o£E  after  a  time. 

Ligation  of  the  internal  saphenous  vein  is  perhaps  the  best  treat- 
ment for  the  varices  of  the  leg  which  are  so  common  (Trendelenburg). 
Trendelenburg  has  practised  this  simple  operation  for  years  with  the 
best  results.  Its  success  is  very  surprising.  Yaricose  ulcers  of  the  leg 
also  heal  with  remarkable  rapidity.  Petersen  recommends  a  circular 
incision  about  the  leg  through  the  skin  and  subcutaneous  tissue  ;  the 
veins  are  in  part  ligated  and  in  part  resected,  and  the  skin  sutured. 

The  bloodless  methods  of  treatment  are,  for  the  most  part,  only 
palliative  in  their  nature.  In  the  varices  of  the  leg,  for  example,  they 
consist  mainly  in  the  use  of  dressings  which  exert  pressure,  particularly 
elastic  stockings,  or  roller  and  elastic  bandages.  In  general,  Martin's 
cheap  elastic  bandage  is  preferable  to  the  elastic  stocking.  If  ulcers 
of  the  leg  are  present,  they  should  be  dusted  with  iodoform,  dermatol, 
bismuth,  or  oxide  of  zinc,  and  over  this  dressing  Martin's  elastic  band- 
age should  be  applied.  With  these  bandages  the  patient  can  attend  to 
his  business.  The  bandages  are  taken  off  in  the  evening,  thoroughly 
washed  in  water,  and  dried  during  the  night.  The  greatest  cleanliness 
is  necessary  in  this  method  of  treatment.  Oftentimes  the  elastic  band- 
age is  not  borne  well,  as  it  causes  an  eczema.  In  this  case  the  rubber 
bandage  should  be  left  off  and  the  eczema  treated  with  diluted  alcohol, 
some  ointment,  or  dusted  with  starch,  or  starch  and  zinc  oxide  (5  to 
10  : 1),  over  which  a  gauze  and  cotton  dressing  is  placed.  In  varices 
of  the  lower  extremity,  Landerer  recommends  compression  of  the 
internal  saphenous  vein  by  a  truss  consisting  of  a  spring  made  in  the 
shape  of  a  parabola,  and  a  pad  filled  with  water ;  this  is  worn  above  or 
below  the  knee. 

Finally,  mention  should  be  made  of  the  injection  of  drugs  into  the 
parts  which  surround  the  veins.  Paul  Yogt  recommends  cutaneous 
and  subcutaneous  injections  of  ergotin  into  the  perivascular  tissues. 
If  this  method  is  employed,  as  fresh  solutions  as  possible  of  ergotin 
should  be  used  (extract,  secal.  cornut.,  "Wernich,  1  to  10  aq.  destil.), 
to  which  it  is  a  good  plan  to  add  a  little  carbolic  acid  (0.10)  to  prevent 
decomposition.  It  is  wise  not  to  permit  the  solution  to  stand  for  too 
long  a  lime,  but  to  renew  it  frequently.  The  solution  is  injected  by  a 
hypodermic  syringe  and  the  small  punctured  wound  closed  by  iodo- 
form collodion.  If  an  abscess  should  result,  it  must  be  promptly  in- 
cised. InjectionSjOf  absolute  alcohol,  or  of  a  few  drops  of  concentrated 
carbolic   acid,  as   in   haemorrhoids,  are    better  than    ergotin  (Lange). 


564    INJURIES  AND   SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 

Care  must  always  be  taken  to  avoid  any  direct  injury  to  the  vein  and 
to  make  the  injections  only  into  the  perivascular  tissues. 

^  96.  The  Diseases  of  the  Lymphatic  System. — The  acute  and  chronic 
inflammations  of  the  lymph  vessels  and  glands  have  been  sufliciently 
descrilied  under  the  subjects  of  inflammation  ( §§  50  to  58),  acute  lym- 
phangitis and  lymphadenitis  (§  68),  tuberculosis,  scrofula,  syphilis,  etc. 
We  shall  return  to  tumours  of  the  lymph  glands  in  the  chapters  on 
Xew  Growths. 

There  only  remains  to  be  briefly  discussed  here  lymphaugiectasiae 
and  Ivrapli  fistulfe  with  lymphorrhcea  or  lymphorrhagia. 

Ljnnphangiectasiae. — Dilatation  of  the  lymphatic  vessels  dymphan- 
giectasisi,  from  obstruction  to  the  return  flow  of  lymph,  occurs  under 
conditions  similar  to  those  which  are  present  in  dilatation  of  the  veins. 
Lvmphangiectasias  are  not  infrequently  observed  as  a  result  of  recur- 
rent attacks  of  hyperaemia  and  inflammations  of  various  kinds.  The 
hyperplasia  of  the  skin  and  subcutaneous  tissue  occurring  in  conjunc- 
tion with  frequently  repeated  inflammations,  and  which  is  called  ele- 
phantiasis, is  in  the  main  a  true  lymphangiectasia  (see  §  93).  But,  as  a 
general  thing,  the  return  flow  of  lymph  ha*  so  many  channels  through 
which  it  can  pass  that  if  stasis  occurs  compensation  readily  takes  place, 
and  for  this  reason  an  occlusion  even  of  the  thoracic  duct  may  cause 
no  serious  trouble.  Lymphangiectasias  are  observed  most  commonly 
in  the  lacteal  vessels  of  the  mesentery.  In  rare  cases,  as  a  result  of 
some  traumatism,  there  occasionally  develop  circumscribed  subcuta- 
neous or  interstitial  collections  of  lymph — so-called  lymph  extravasa- 
tions or  lymph  cysts  similar  to  the  hsematomata  derived  from  the  blood- 
vessels. 

As  regards  the  symptoms  which  lymphangiectasiae  give  rise  to,  it 
should  be  briefly  stated  that  in  lymphangiectasia?  of  the  skin  the  latter 
is  filled  with  dilated,  tortuous  lymph  vessels :  the  skin  for  this  reason 
has  a  nodular  appearance :  it  is  covered-  with  vesicles,  and  frequently, 
as  a  result  of  hyperplasia  of  the  tissues,  comes  to  resemble  elephantia- 
sis. If  the  varices  of  the  lymphatic  network  in  the  cutis  are  more  pro- 
nounced, vesicles  of  different  size  develop.  Xot  infrequently  the  vari- 
cose lymphatic  vessels  burst  and  give  rise  to  a  so-called  lymph  fistula. 
Gjeorgewic  states  that  in  fifty-five  cases  lymphorrhoea  was  observed 
twenty-two  times  in  consequence  of  the  spontaneous  bursting  of  the 
varicose  lymph  vessels.  The  lymph  usually  exudes  from  one  or  more 
vesicles  and  sometimes  from  between  the  epithelial  cells,  as  in  one  case 
which  I  saw,  without  an  actual  fistula  being  visible.  Under  these  cir- 
cumstances, the  escape  of  lymph,  the  lymphorrhagia  or  lymphon-hcea 
may  be  very  considerable.     In  one  case  of  lyraphangiectasis  of  the  labia 


§96.]  THE  DISEASES  OP  THE  LYMPHATIC  SYSTEM.  565 

majora  in  which  a  fistula  developed,  ISTieden  found  that  in  four  hours 
there  was  an  escape  of  one  and  a  half  litre  of  a  milky,  slightly  yellow- 
ish liquid  containing  fat  and  resembling  chyle.  The  most  serious 
lymphorrhagia  is  that  which  results  from  a  rupture  of  the  thoracic 
duct  caused,  for  instance,  by  a  traumatism  or  by  an  advanced  degree 
of  stasis,  possibly  from  closure  of  its  lumen  by  inflammation  or  a  tu- 
mour in  its  neighbourhood.  In  such  instances  there  is  a  great  accu- 
mulation of  lymph  in  the  thoracic  and  abdominal  cavities  (chylous  hy- 
drothorax  and  chylous  ascites),  which  will  be  described  in  the  Regional 
Surgery. 

In  the  rare  cases  of  circumscribed,  subcutaneous,  and  interstitial 
collections  of  lymph  which,  as  a  result  of  a  traumatism,  for  example, 
has  escaped  from  the  vessels,  there  develops  a  fluctuating,  circum- 
scribed swelling  which  at  the  outset  grows  rapidly  and  then  usually 
remains  stationary  (lymph  cysts).  Should  the  extravasation  of  lymph 
continue,  a  lymph  fistula  may  eventually  form  from  a  rupture  of  the 
skin. 

The  microscopic  changes  in  lymphangiectasias  of  the  skin  consist 
principally  in  the  development  of  numerous  irregularly  shaped,  com- 
plex cavities,  lying  in  and  close  beneath  the  papillary  layer  of  the  cutis 
and,  in  fact,  directly  beneath  the  epidermis,  which  are  lined  with  endo- 
thelium and  communicate  with  the  plexus  of  lymphatic  vessels.  Not 
infrequently  lymphatic  vessels  with  hypertrophic  walls  are  found  in 
the  deepest  layers  of  the  cutis  and  subcutaneous  cellular  tissue. 

Congenital  Lymphangiectasis. — The  lymphaugiectasis  is  sometimes 
congenital,  particularly  in  the  tongue  and  lips  (macroglossia,  macro- 
cheilia  lymphangeiectatica),  and  also  in  the  skin  of  the  scrotum  and 
labia  pudendi. 

Treatment  of  Lymphangiectasis,  Extravasations  of  Lymph  (Lymph 
Cysts)  and  Lymph  Fistulse. — The  treatment  of  lymphangiectasiae  is  in 
general  the  same  as  for  varicose  veins,  and  often  enough  it  is  unsuc- 
cessful. In  many  cases  cauterisation  with  the  fine  point  of  the  Paquelin 
or  galvano-cautery  renders  excellent  service.  Successful  extirpation 
may  prove  very  difficult  for  the  reason  that  the  boundary  between  the 
diseased  and  healthy  tissues  is  so  hard  to  recognise.  For  lymph  cysts 
compression  should  be  tried,  and  if  this  fails,  the  sac  should  be  laid 
open  with  or  without  cauterisation  of  its  walls  with  a  three-  to  five- 
per-cent.  solution  of  carbolic  acid.  Lymph  fistulse  have  been  cured  by 
transverse  division  of  the  skin  on  the  proximal  side  of  the  fistula.  As 
regards  the  treatment  of  elephantiasis,  injuries  of  the  thoracic  duct, 
and  congenital  lymphangiectasiae,  I  must  refer  the  reader  to  Regional 
Surgery. 


566    INJURIES  AND  SURGICAL   DISEASES  OF  THE  SOFT    PARTS. 

§  97.  The  Diseases  of  the  Peripheral  Nerves. — We  shall  confine  our- 
selves here  only  to  the  surgical  aspects  of  diseases  of  the  nerves — i.  e., 
we  shall  only  take  up  those  which  are  capable  of  surgical  treatment. 
We  have  already,  in  a  previous  chapter,  discussed  the  most  important 
diseases  of  the  peripheral  nerves.  Degeneration  and  regeneration  of 
nerves,  following  contusion  or  division  of  them,  has  been  described  in 
§§  87  and  88,  where  the  sequelae  of  injuries  to  nerves,  the  paralyses, 
and  the  vasomotor  and  trophic  disturbances  have  been  discussed. 
Trismus  and  tetanus  have  been  described  under  the  subject  of  Infec- 
tious Diseases  of  Wounds  (§  73),  and  the  symptoms  of  shock  in  conse- 
quence of  injury  to  the  sensory  nerves  in  §  63.  Inflammation  of  the 
peripheral  nerves  (neuritis)  has  been  described  in  connection  with  in- 
juries of  nerves  (§  87),  but  the  subject  must  be  briefly  reviewed  at 
this  place. 

Neuritis. — J^euritis  occurs  in  an  acute  and  chronic  form.  The  most 
common  causes  of  neuritis  are  injuries  of  various  kinds,  catching  cold, 
inflammations  of  neighbouring  organs,  and  acute  or  chronic  constitu- 
tional diseases,  such  as  typhoid  fever,  the  acute  exanthemata,  diph- 
theria, syphilis,  leprosy,  chronic  alcoholism,  etc.  All  infectious  pro- 
cesses are  of  the  greatest  importance  in  the  etiology  of  diseases  of  the 
peripheral  and  central  nervous  system.  Often  enough  no  definite 
cause  for  the  neuritis  can  be  demonstrated. 

Anatomically,  acute  neuritis  is  characterised  by  redness  and  swell- 
ing and  generally  by  a  serous,  or  sero-fibrinous  or  purulent  exudation 
between  the  bundles  of  nerve  fibres.  Microscopically,  in  addition  to 
the  above-mentioned  manifestations  of  hypersemia  and  inflammatory 
exudation  there  is  found  a  commencing  degeneration  of  the  medullary 
sheath  and  axis  cylinder  of  the  nerve  fibres,  and  a  proliferation  of  the 
nuclei  in  the  sheath  of  Schwann,  Occasionally  the  nerve  perishes 
more  or  less  completely  from  suppuration  or  gangrene.  In  chronic 
neuritis  there  is  partly  a  new  formation  of  connective  tissue,  an  indura- 
tion and  sclerosis  of  the  nerve,  and  partly  a  degeneration  of  the  nerve 
substance.  In  a  man  who  died  of  alcoholism  Eichhorst  found  a  pe- 
culiar degenerative  atrophy  of  the  peripheral  nerve  fibres  without  con^ 
nective-tissue  growth  (neuritis  fascians) ;  there  was  also  a  correspond- 
ing atrophy  of  the  muscles. 

The  symptoms  of  neuritis,  as  far  as  they  concern  the  surgeon,  have 
been  described  in  §  87,  under  Injuries  of  Kerves.  For  further  par- 
ticulars we  must  refer  the  reader  to  the  text-books  on  the  pathology  of 
nerves.  We  have  remarked  before  that  neuritis  gradually  extends  in 
the  form  of  an  ascending  and  descending  neuritis  and  gives  rise  to  cor- 
responding disturbances.     The  treatment  of  neuritis  depends  upon  the 


§  97.]  THE  DISEASES  OF  THE  PERIPHEEAL  NERVES.  567 

cause.     In  the  main,  the  surgeon  has  to  deal  with  injuries  to  nerves,  of 
which  the  therapy  lias  been  given  in  §  88. 

Multiple  Neuritis. — Particular  interest  attaches  to  multiple  neuritis,  in 
the  study  of  which  Leyden  has  won  great  ci'edit.  He  distinguishes  the  fol- 
lowing forms :  1.  The  infectious  form  :  paralyses  following  diphtheria, 
typhoid,  and  other  infectious  diseases,  multiple  neuritis  in  syphilis  and 
tuberculosis.  2.  The  toxic  form  of  multiple  neuritis  (lead,  arsenic,  and 
phosphorous  paralysis,  paralyses  following  CO  and  CS  poisoning,  ergotism, 
mercurial  paralyses,  alcoholic  neuritis).  3.  Spontaneous  multiple  neuritis 
following  over-exertion,  exposure  to  cold,  etc.  4.  The  atrophic  (dyscrasic, 
cachectic)  form  following  anasmia  (pernicious  anaemia),  chlorosis,  marasmus, 
cancerous  cachexia,  diabetes,  and  tuberculosis.  5.  The  sensory  neuritis,  pseu- 
do-tabes, neuro-tabes  peripherica :  a,  the  sensory  form  of  multiple  neurites ; 
b,  the  sensory  neuritis  of  tabes.  The  pathogenesis,  course,  and  treatment 
will  be  found  in  the  text-books  on  nervous  diseases. 

The  relationship  of  the  nervous  system  to  diseases  of  the  skin  has 
heen  briefly  stated  in  §  93,  and  we  shall  return  to  the  subject  of  neuro- 
pathic bone  and  joint  affections  under  Diseases  of  Joints,  l^ew 
growths  of  nerves  are  described  under  the  subject  of  Tumours. 

Traumatic  Neurosis. — Traumatic  neurosis  or  traumatic  hysteria,  which  is 
caused  by  concussion  of  the  brain  and  spinal  cord  from  a  fall,  railroad  acci- 
dents, severe  contusions,  etc.,  and  sometimes  by  comparatively  slight  acci- 
dents, has  already  been  described  on  page  285.  Tlie  treatment  of  the  trau- 
matic neuroses  is  a  subject  that  belongs  to  neurology. 

Neuralgia. — By  neuralgia  (from  vevpov  and  ak<yo<i)  is  understood  a 
disease  of  the  sensory  nerves  the  chief  symptom  of  which  is  pain.  The 
pain  is  usually  localised  in  a  particular  nerve,  is  of  considerable  inten- 
sity, and  is  generally  intermittent  or  remittent.  The  neuralgias  belong 
to  the  most  common  neuroses,  and  their  causes  are  very  numerous. 
There  often  exists  a  pronounced  neuropathic  disposition.  Of  the 
most  common  causes  there  may  be  mentioned  in  particular  trauniatic 
a,nd  mechanical  influences,  inflammations,  compression,  disturbances  of 
circulation,  also  taking  cold,  infections  like  syphilis,  malaria,  poisoning 
by  lead  or  mercury,  and  finally  diseases  of  the  central  nervous  system, 
etc.  Gussenbauer  has  directed  attention  to  the  fact  that  habitual  con- 
stipation is  a  comparatively  frequent  cause  of  trigeminal  neuralgia, 
and  I  can  confirm  his  experiences  throughout.  The  pain  usually  comes 
on  in  attacks  of  varying  intensity  and  duration.  The  course  of  the 
neuralgia  is  sometimes  acute — a  few  days  or  a  week — and  sometimes 
chronic,  extending  over  weeks,  months,  or  years.  A  large  number  of 
the  cases  are  incurable,  and  last  throughout  the  rest  of  life.  Neural- 
gias of  the  trigeminus,  the  sciatic  and  intercostal  nerves  are  particu- 
larly common. 


568    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT   PARTS. 

Treatment  of  Neuralgia. — The  treatment  of  neuralgia  requires  first 
of  all  that  the  cause  of  the  disease  should  be  determined  bj  a  careful 
examination  of  the  patient.  By  overcoming  habitual  constipation, 
ansemia,  affections  of  the  genital  apparatus,  especially  in  women,  etc., 
surprising  cui*es  of  long-standing  reflex  neuralgias  have  often  been 
brought  about. 

The  forms  of  treatment  of  neuralgia  itself  are  very  numerous,  and 
include  particularly  the  use  of  electricity,  narcotics  (morphine,  atro- 
pine), especially  in  the  form  of  subcutaneous  injections,  and  various 
drugs,  such  as  chloroform,  ether,  nitrite  of  amyl,  and  chloral  hydrate ; 
also  the  internal  administration  of  arsenic,  quinine,  preparations  of  iron, 
bromide  of  potassium,  iodide  of  potassium,  and  strychnine.  Among  the 
newer  drugs  used  for  neuralgia  are  antipyrine,  antifebrine,  phenacetine, 
agathin  (one  half  gramme  for  adults  three  times  a  day),  and  migranin 
(one  and  one-tenth  gramme  for  adults  three  times  a  day).  Surgical  meas- 
ures are  often  indicated,  e.  g.,  massage,  nerve-stretching,  neurotomy, 
neurectomy,  extraction  of  the  nerve,  or  neurolysis,  i.  e.,  liberation  of  a 
nerve  that  is  compressed  by  a  cicatrix,  callus,  etc.  Electricity  is  some- 
times very  effective,  especially  the  galvanic  current.  In  addition  to  the 
above-mentioned  remedies,  counter-irritation  of  the  skin,  powerful  elec- 
trical stimulation,  vesicants,  the  red-hot  iron,  etc.,  may  be  tried.  In 
suitable  cases  there  is  great  advantage  in  sea-bathing  or  in  hot  springs 
(Gastein,  Schlangenbad,  Pfaffers,  Ragatz,  Wildbad,  Wiesbaden,  Tep- 
litz,  Leuk,  etc.),  or  in  cold-water  cures,  grape  cures,  and  particularly  in 
mountain  hfe  with  proper  exercise.      Massage  is  often  very  successful. 

Neurectomy  and  Extraction  of  the  Nerves. — The  surgical  or  opera- 
tive treatment  of  neuralgia  by  neurectomy  or  extraction  of  the  diseased 
nerves  only  succeeds  when  the  neuralgia  is  dependent  upon  a  peripheral 
cause.  But  even  in  such  cases  recurrences  often  occur,  although  no 
reunion  of  the  divided  nerve  has  followed  the  operation.  After 
extraction  of  the  affected  nerve,  the  collateral  branches  which  have 
been  left  intact  may  give  rise  to  a  recurrence,  and  permanent  cures 
after  neurectomy  are  rare,  as  is  shown  by  the  recent  statistics  of  Con- 
rad taken  from  the  clinic  at  Bonn.  Operations  were  performed  ten  to 
fifteen  times  for  a  facial  neuralgia,  for  example,  without  a  single  per- 
manent cure. 

The  technique  of  neurectomy  and  of  extraction  of  the  diseased 
nerves  is  described  in  the  Regional  Surgery. 

Nerve-stretching. — I^erve-stretching  was  first  practised  by  Billroth 
and  Xussbaum  for  chronic  affections  of  the  nerves,  for  epileptiform 
attacks,  and  for  neuralgias,  and  has  been  employed  with  greatly  vary- 
ing success  for  sciatica,  tabes,  and  other  nervous  diseases.     The  opera- 


§98.]  THE  DISEASES   OF  MUSCLES.  569 

tion  is  performed  by  exposing  and  isolating  the  sciatic  nerve,  for 
instance,  above  the  popUteal  space  or  higher  up  at  the  lower  border  of 
the  glutseus  maximus,  and  having  grasped  the  nerve  with  the  thumb 
and  index-iinger,  it  is  stretched  by  a  vigorous  pull  until  it  has  become 
plainly  lengthened.  Nerve-stretching  is  only  indicated  in  diseases  of 
the  peripheral  nerves  and  not  in  aifections  of  the  central  nervous 
system.  The  effects  of  nerve-stretching  are  probably  due  to  the  pro- 
duction of  an  acute  traumatic  inflammation  of  the  parts  surrounding 
the  exposed  nerve,  by  which  pathological  conditions,  such  as  degenera- 
tive processes,  adhesions,  etc.,  are  improved.  In  cases  of  spasm  of 
the  facial  nerve,  and  in  severe  cases  of  long-standing  sciatica,  I  have 
practised  nerve-stretching  with  good  results. 

Bloodless  Stretching  of  the  Sciatic. — For  neuralgia  of  the  sciatic 
nerve  (sciatica)  it  is  an  excellent  plan  to  employ  bloodless  stretching  by 
extreme  flexion  of  the  straightened  leg  at  the  hip  joint,  combined  wdth 
massage. 

§  98.  The  Diseases  of  Muscles,  Tendons,  and  Tendon  Sheaths. — Inflam- 
mation of  muscles  (myositis)  originates  most  commonly  from  trauma- 
tisms, and  secondarily  from  inflammation  of  the  immediately  adjoin- 
ing parts  as  a  result  of  disturbances  of  circulation,  or  in  the  course  of 
infectious  bacterial  diseases  (pyaemia,  typhoid,  glanders,  etc.).  The 
inflammatory  process  in  the  muscle  is  localised  principally  in  the  con- 
nective tissue  lying  between  the  primitive  muscular  fasciculi,  in  the 
perimysium  internum,  and  causes  secondary  changes  in  the  contractile 
muscular  substance.  In  other  cases  the  latter  is  primarily  the  seat,  for 
instance,  of  atrophy  and  degeneration,  and  the  changes  in  the  inter- 
muscular connective  tissue  are  secondary. 

Inflammatory  Muscular  Contracture. — Apart  from  the  local  inflam- 
matory disturbances  occurring  in  the  various  forms  of  myositis,  con- 
tracture of  the  inflamed  muscle  is  one  of  the  most  important  manifes- 
tations. We  shall  discuss  the  subject  of  contractures  more  fully  later 
on,  and  we  shall  see  that  they  may  originate  from  many  causes,  such  as 
disease  of  the  muscles,  nerves,  bones,  and  joints,  or  from  cicatricial 
shrinkage.  As  regards  inflammatory  contractures,  it  may  be  briefly 
noted  that  every  inflamed  muscle  loses  its  elasticity  and  extensibility  to 
a  greater  or  less  extent,  and  that  the  patient  instinctively  avoids  the 
pain  due  to  the  stretching  of  the  muscle  by  shortening,  oi-,  in  other 
words,  contracting  it.  The  inflammatory  muscular  contracture  origi- 
nates in  this  way,  and  may  become  very  severe.  In  this  class  of  in- 
flammatory, purely  myogenic  contractures,  belong  also  the  so-called 
ischsemic  muscular  paralyses  and  muscular  contractures,  such  as  those 
which  follow  the  too  tight  application  of  dressings,  and  which  were 


570    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT   PARTS. 

:first  accurately  described  by  Volkmann,  and  then  by  Leser.  The 
isch?ernic  contractures  and  paralyses  are  produced  by  cutthig  off  the 
arterial  supply,  especially  of  the  hand  and  forearm,  for  too  long  a  time 
by  tight  dressings,  Esmarch's  constriction,  ligation  and  injuries  of  the 
larger  vessels,  as  well  as  by  the  prolonged  action  of  excessive  cold. 
The  contractile  muscular  substance  coagulates,  undergoes  waxy  degen- 
eration, and  is  subsequently  absorbed  (Heidelberg,  Kraske).  There  is 
regularly  found  a  noticeable  diminution  or  absence  of  muscular  nuclei 
(Molitor),  and  the  nuclei  of  the  smallest  capillaries  also  share  in  these 
changes.  In  such  cases  the  muscle  is  no  longer  capable  of  regenera- 
tion ;  it  dies.  It  is  really  a  rigor  mortis  of  the  muscle,  though  the 
nerves  retain  their  power  of  conduction.  If  the  ischsemia  does  not  last 
so  long  a  time,  only  a  part  of  the  muscular  fibres  undergo  degenera- 
tion, and  the  rest  persist  and  retain  their  power  of  regeneration.  The 
ischseraic  contracture  is  marked  by  a  high  grade  of  resistance  to  exten- 
sion into  a  straight  position.  The  prognosis  of  the  ischsemic  paralysis 
and  contracture  depends  uj)on  the  number  of  muscular  fibres  which 
have  perished,  the  worst  cases  being  incurable,  and  even  the  milder 
ones  requiring  vigorous  treatment  by  massage,  electricity,  and  passive 
motion.  An  attempt  should  always  be  made  to  stretch  the  shortened 
and  stiffened  muscles,  if  necessary,  under  chloroform  narcosis. 

Myositis  Serosa  and  Sero-fibrinosa. — The  slight  degrees  of  inflamma- 
tion of  muscle — the  myositis  serosa  and  sero-fihrinosa — which  may 
follow  contusions,  for  example,  are  characterised  anatomically  by  a 
saturation  of  the  perimysium  with  serum  and  by  cellular  infiltration, 
particularly  between  the  muscle  fibres.  The  latter  remain  intact,  or, 
according  to  the  nature  of  the  excitant  of  the  inflammation,  they  un- 
dergo a  cloudy  swelling,  fatty  degeneration,  and  coagulation  necrosis. 
The  defect  in  the  contractile  muscular  flbres  is  more  or  less  restored 
by  proliferation  of  the  muscular  corpuscles  (see  page  483,  Regeneration 
of  Muscle).  If  a  severer  grade  of  inflammation,  such  as  a  jpuriilent 
myositis,  occurs,  the  muscular  fibres  are  destroyed  en  masse  by  degen- 
erative processes ;  they  break  down  and  undergo  suppuration  and 
putrefaction.  Myositis  purulenta  may  be  acute  or  chronic,  taking  the 
form  of  muscular  abscesses  or  of  a  diffuse  suppuration  or  putrefaction, 
as  described  in  the  chapter  on  Cellulitis.  The  suppurative  and  gan- 
grenous inflammations  of  muscle  ai-e  always  due'  to  bacterial  infection, 
and  are  observed  in  conjunction  with  infected,  septic  wounds  of  vari- 
ous kinds,  occurring  in  the  course  of  pyeemia,  erysipelas,  typhoid, 
glanders,  endocarditis,  etc.  Multiple  abscesses  in  different  muscles 
often  occur  in  great  numbers.  The  muscular  abscess  occurring  in 
the  course  of  tuberculosis,  the  so-called  cold  abscess,  such  as  the  tuber- 


§98.]  THE  DISEASES  OF  MUSCLES.  571 

cular  abscess  or  suppuration  of  the  psoas  muscle  following  tubercular 
disease  of  the  vertebrae,  runs  an  exceedingly  chronic  course  unless  it 
receives  energetic  surgical  treatment.  Diffuse  suppurative  and  gan- 
grenous changes  in  muscle  are  particularly  apt  to  make  their  appear- 
ance in  conjunction  with  a  compound  fracture  which  has  not  been 
treated  aseptically. 

Wherever  muscular  tissue  has  been  destroyed  by  suppuration  or 
gangrene  there  will  remain,  after  healing  has  taken  place,  a  permanent 
defect  which  is  repaired  by  connective  tissue,  since,  as  we  remarked 
on  page  483,  contractile  muscular  substance  possesses  but  slight  powers 
of  repair.  Corresponding  to  the  size  of  the  defect,  the  connective- 
tissue  adhesions  and  the  increasing  cicatricial  contraction,  disturbances 
in  the  functions  of  the  muscles  will  subsequently  develop  in  the  form 
of  contractures,  which  may  render  the  affected  extremity  completely 
useless. 

Myositis  Fibrosa. — Chronic  inflammations  of  muscle  sometimes  take 
the  form  of  a  myositis  fibrosa.  In  this  we  have  to  deal,  in  the  main, 
with  a  growth  of  firm  connective  tissue  between  the  muscular  fasciculi 
and  a  proportionate  atrophy  of  the  latter.  This  fibrous  myositis,  or 
sclerosis  of  a  muscle,  occurs  either  diffusely,  changing  the  entire  mus- 
cle into  tough  connective-tissue  masses,  or  it  is  confined  to  certain 
spots.  In  this  category  belong  the  myositis  fibrosa  of  the  biceps  or 
sterno-mastoid  muscles,  for  example,  occurring  in  the  course  of  syphi- 
lis, or  after  paralyses,  or  primary  muscular  atrophies  due  to  different 
causes,  and  also  the  so-called  rheumatic  indurations.  In  the  latter  the 
infiammatory  process — i.  e.,  the  interstitial  myositis — begins  in  the 
lymph  vessels  and  small  veins  and  leads  to  the  production  of  a  vascular 
connective  tissue  and  to  secondary  atrophy  of  the  muscle-fibres.  The 
inflammation  is  probably  due  to  micro-organisms.  The  treatment  of 
these  indurations  consists  in  warm  local  baths,  massage,  inunctions  of 
unguentum  cinereum,  and  possibly  in  excision  (Strauss).  Indurations 
of  muscle  may  also  result  from  the  invasion  and  encapsulation  of 
trichinse  (Curschmann). 

Myositis  Ossificans. — Special  interest  attaches  to  myositis  ossifians. 
The  development  of  bone  in  muscle  is  observed  under  various  patho- 
logical conditions ;  for  example,  in  conjunction  with  callus  formation 
after  a  fracture.  Bone  occasionally  forms  in  muscle  as  a  result  of 
some  frequently  repeated  traumatism,  such  as  the  kick  of  a  gun,  which 
may  give  rise  to  the  development  of  bone  in  the  biceps  and  pectoralis 
muscles  (the  so-called  exercise  bones).  Riding  may  lead  to  bony  for- 
mation in  the  adductors  of  the  thigh  (riders'  bone).  Two  kinds  of 
myositis  ossificans  can  be  distinguished.     In  one  form  the  new  forma- 


572    INJURIES  AND  SURGICAL  DISEASES  OF   THE   SOFT   PARTS. 


tion  of  bone  starts  in  the  periosteum  and  involves  tlie  muscle  second- 
arily, and  in  the  other  variety  it  begins  in  the  muscle,  and  the  new  bone 
either  remains  independent  of  the  periosteum  or  becomes  connected 
later  with  the  periosteum  and  bones.  The  affection  is  probably  of 
traumatic  origin,  particularly  the  first  form  ;  a  single  trauma  or  repeated 
traumatic  influence  gives  rise  to  an  ossifying  periostitis  which  spreads 
to  the  muscle  secondarily,  particularly  at  its  point  of  insertion  on  the 
bone.  It  is  really  an  exostosis  formation  which  spreads  to  the  muscle 
as  in  the  very  interesting  case  described  by  Lange  (see  page  OUT, 
Fig.  -lOS).     In  rare  cases  free  osteomata  are  found  whicli  are  not  con- 


FiG.  3S5. — Os^ified  M.  braehiali-  inicrnus:  the 
tendon  is  not  ossified  (Blasius  and  Volk- 
mann ). 


Fig.  386. — Myositis  ossificans  multiplex  pro- 
gressiva of  the  muscles  of  the  hack  in  a 
man  twenty-four  years  old  (Helfreicht. 


nected  with  the  bone.  In  those  instances  the  osteoma  formation  may 
be  caused  by  a  local  congenital  anomaly  of  development  as  assumed  in 
the  case  of  myositis  ossificans  multiplex  progressiva  (see  below).  It  is 
also  possible  that  here  too  traumatism  may  be  of  etiological  importance. 
One  can  imagine  that  in  consequence  of  an  injury  periosteum  or  small 
fragments  of  bone  may  become  lodged  in  the  neighbouring  connective- 
tissue  or  muscle,  or  that  osteoblasts  may  be  carried  by  the  circulation 
from  some  point  of  injury  of  the  periosteum  or  bone  to  the  muscle, 
and  in  this  way  give  rise  to  the  formation  of  an  osteoma.  Fig.  385 
represents  a  case  in  which  the  brachialis  anticus  was  completely  changed 
into  bone.  Diims  observed,  in  connection  with  the  formation  of  bone 
in  the  deltoid  nausele,  a  reflex  neurosis,  consisting  of  tremor  and  pains 


§98.]  THE   DISEASES   OF  MUSCLES.  573 

in  the  entire  arm  down  to  the  finger  tips,  which  only  occurred  when 
the  gun  pressed  upon  the  exercise  bone  (osteoma),  and  disappeared 
completely  after  its  extirpation. 

Myositis  Ossificans  Multiplex  Progressiva. — This  is  a  very  peculiar 
affection  which  sometimes  begins  during  childhood.  A  great  number 
of  muscles  gradually  change  into  bone,  causing  the  condition  of  the 
patient  to  become  extremely  deplorable.  The  disease  runs  a  very 
chronic  course,  lasts  for  years,  and  is  often  characterised  by  typical 
attacks  of  fever  and  pains  with  subsequent  bone-formation.  After 
the  reception  of  some  slight  traumatism,  or  without  any  apparent 
reason,  painful  doughy  swellings  develop  in  the  muscles  and  iuter- 
muscular  connective  tissue,  and  in  a  few  days  they  disappear.  A  pre- 
liminary stage  of  fibrous  induration  can  usually  be  made  out  (Lexer). 
Inflammatory  fibrous  proliferation  of  the  perimysium  internum  and 
degeneration  of  the  muscular  fibres  result  in  the  formation  of  fibrous 
nodules  primarily  in  the  muscle  and  independent  of  the  bone.  True 
bone  is  then  gradually  formed,  partly  from  the  bone  itself  in  the 
vicinity  of  the  muscular  insertions  and  partly  in  the  muscle.  ISTodular, 
branching  masses  of  bone  develop,  especially  in  the  muscles  of  the 
back  and  neck  (Fig.  386).  The  jaws  may  be  firmly  held  together  by. 
ossification  of  the  masseters,  and  the  movements  of  the  vertebree  and 
the  different  joints  may  become  lost  in  consequence  of  the  ossification 
of  the  muscles,  tendons,  and  ligaments.  These  pitiable  individuals 
finally  die  in  misery  from  motor  disturbances,  or  from  interference 
with  respiration  and  nutrition. 

The  nature  of  this  very  remarkable  disease  is  still  but  little  understood. 
Thei'e  is  evidently  a  pronounced  tendency  to  the  formation  of  bone  in  the 
connective  tissue  of  the  muscles,  fascia,  tendons,  and  ligaments,  as  though 
periosteum  had  strayed  into  these  tissues.  The  affection  is,  in  all  probability, 
a  congenital  anomaly  of  development,  especially  as  in  some  cases  malforma- 
tions of  the  extremities  have  been  present  at  the  same  time  (micro-dactylism, 
congenital  anchylosis  of  the  joints  of  the  big  toes  and  of  the  thumbs) 
Stempel  regards  the  process  as  an  imperfect  differentiation  of  the  original 
embryonic  gelatinous  tissue  representing  the  mesenchyma  from  which  on 
the  one  side  connective  tissue  and  on  the  other  cartilage  and  bone-tissue 
develop.  If  this  normal  differentiation  is  disturbed  cartilage  and  bone 
develop  in  places  which  should  be  filled  only  with  connective  tissue.  Pincus 
has  advanced  the  theory  that  the  disease  is  in  the  main  traumatic  in  nature, 
and  is  probably  caused  by  lesions  of  the  soft  j)arts  at  the  time  of  delivery. 
It  is  perhaps  possible  that  the  new  formation  of  bone  is  caused  by  osteoblasts 
which  are  carried  through  the  circulation.  The  chief  question  is :  Where 
does  the  bone  originate  ?  In  the  intermuscular  connective  tissue,  in  the  mus- 
cle, or  from  periosteum  and  bone,  and  then  invade  the  muscle  secondarily  ? 
Both  ways  are  possible.     I  believe  with  Virchow  tbat  in  most  cases  the  new 


574    INJURIES  AND  SURGICAL  DISEASES  OP  THE  SOFT  PARTS. 

bone  formation  starts  in  the  periosteum  or  bone  and  then  extends  to  the 
muscles  secondarily  ;  in  other  words,  that  there  is  a  multiple  exostosis  forma- 
tion with  secondary  ossification  of  the  muscle  and  connective  tissue.  Besides 
this  there  are  cases  where  new  bone  develops  primarily  in  the  intermuscular 
connective  tissue  and  the  muscle  itself  and  is  not  connected  with  the  bone, 
so  that  the  bony  tumour  can  be  grasped  witli  the  hand  and  moved  freely.  In 
the  latter  case  this  ossification  takes  place  according  to  the  endochondral  as 
well  as  the  periosteal  type.  In  a  typical  case  which  Stempel  observed  for 
three  years  and  a  half  the  formation  of  bone  started  in  the  connective  tissue. 
In  a  similar  case  of  Roth's  almost  all  the  bony  growths  were  connected  with 
the  bone  itself.  I  think  the  disease  should  be  looked  upon  not  as  an  inflam- 
matory process,  but  as  a  tumour  formation — i.  e.,  either  multiple  exostoses 
or  multiple  intramuscular  osteomata  in  the  connective  tissue. 

The  treatment  of  the  severe  eases  of  myositis  ossiiicans  offers  no 
hope,  but  the  milder  cases  may  derive  some  benefit  from  iodide  of 
potassium  and  inunctions  of  ungt.  hydrarg.  ciuer.  Whenever  possil)le, 
operative  measures  should  be  undertaken — i.  e.,  the  ossified  muscle 
should  be  extirpated,  and,  if  it  be  connected  with  the  periosteum  and 
bone,  the  periosteum  and  cortical  layer  of  bone  should  also  be  removed. 

The  treatment  of  the  above-mentioned  acute  and  chronic  inflamma- 
tions of  muscle  is  conducted  upon  the  lines  which  have  been  laid  down 
for  the  treatment  of  inflammation  and  suppuration. 

Calcification  of  the  Muscles  has  no  clinical  importance.  It  occurs  in  the 
neighbourhood  of  inspissated  abscesses  and  in  indurated  inflammatory  swell- 
ings. Extensive  calcification,  such  as  Meyer  observed  in  the  muscles  of  the 
leg,  is  exceedingly  rare. 

Muscular  Rhetunatism. — Acute  and  chronic  muscular  rheumatism 
depend  upon  inflammatory  changes  which  are,  to  be  sure,  slight  in 
amount.  There  are  usually  no  gross  anatomical  changes  in  a  chronic 
muscular  rheumatism  which  has  lasted  for  years ;  but  the  acute  form, 
is,  for  the  most  part,  a  serous  or  sero-fibrinous  myositis.  We  still 
know  but  very  little  about  the  nature  of  muscular  rheumatism.  The 
manifestations  of  acute  muscular  rheumatism  are  very  much  like  those 
exhibited  after  subjecting  the  muscles  to  some  traumatism.  The  chief 
symptom  consists  in  the  more  or  less  severe  pains  in  the  muscle.  It 
occurs  especially  as  lumbago  and  as  rheumatism  of  the  sterno-mastoid 
muscle  (rheumatic  torticollis).  In  addition  to  the  rheumatic  forms  of 
lumbago  there  is  also  a  traumatic  form  which  follows,  for  example, 
forced  forward  flexion  of  the  back.  The  rheumatic  affection  of  the 
sterno-mastoid  is  usually  accompanied  by  a  marked  contraction  of  the 
muscle,  causing  the  head  to  be  inclined  toward  the  affected  side. 

Chronic  muscular  rheumatism  is  characterised  by  shooting,  tearing, 
generally  vague  pains  in  the  substance  of  the  muscle,  which  are  usually 


§98.]  THE  DISEASES  OF  MUSCLES.  575. 

excited  or  increased  by  bad  weather.  In  the  subsequent  course  of  a 
given  muscular  rheumatism  it  often  turns  out  that  some  constitutional 
disease  is  present,  such  as  syphilis,  tuberculosis,  carcinoma,  etc.  I 
share  Erben's  opinion  that  true  muscular  rheumatism  is  rare,  and  that 
it  is  often  made  to  include  other  diseases,  such  as  neuralgia,  inflamma- 
tions of  neighbouring  joints — e.  g.,  of  the  spine  in  cases  designated  as 
lumbago.  In  every  case  one  should  determine  where  the  pain  on 
pressure  exists,  whether  in  the  muscles,  nerves,  bone,  or  joints,  and 
the  treatment  should  be  directed  toward  the  diseased  condition  that 
is  found.  The  best  treatment  for  the  true  acute  and  chronic  muscu- 
lar rheumatism  consists,  according  to  my  experience,  in  the  use  of 
massage,  in  the  diligent  exercise  of  the  affected  muscles,  and  also  in. 
cold-water  cures  and  the  use  of  warm  springs  (Teplitz,  Wiesbaden, 
Rehme,  Gastein,  etc.).  Electricity  is  also  serviceable ;  but  massage, 
skilfully  administered  and  combined  with  muscular  exercise,  is  the 
best  therapeutic  measure. 

Tuberculosis  of  Muscles. — Tuberculosis  of  the  muscles  is  most  com- 
monly secondary  to  tubercular  disease  of  the  surrounding  parts,  or  it 
follows  deposition  of  the  tubercle  bacilli  by  the  circulation,  such  as 
occurs  in  general  miliary  tuberculosis  (see  §  83,  Tuberculosis). 

Syphilis  of  Muscles. — Syphilis  may  become  localised  in  muscles, 
occurring  sometimes  in  a  diffuse  form,  as  myositis  fibrosa,  and  some- 
times circumscribed,  as  a  gumma  tumour,  especially  in  the  sterno- 
mastoid  muscle.  Braman  is  right  in  calling  attention  to  the  fact  that 
many  of  the  so-called  rheumatic  indurations  of  muscle  are  due  to 
syphilis. 

Muscular  Atrophy. — Atrophy  of  the  muscles  is  observed  in  yarious 
pathological  conditions.  Atrophy  and  degeneration  may  follow  inac- 
tivity of  the  muscles  (atrophy  of  disuse),  such  as,  for  example,  occurs 
temporarily  after  the  application  of  immobilising  dressings  for  fractures 
or  joint  disease  ;  or  it  may  be  due  to  disease  of  the  central  or  periph- 
eral nervous  system  (neuropathic  atrophies),  or  to  the  above-mentioned 
inflammatory  processes,  traumatisms,  etc.  The  muscular  atrophy 
accompanying  joint  affections  is  sometimes  not  the  result  of  disuse,^ 
but  is  caused  by  the  local  disease  near  by — that  is,  by  an  involve- 
ment of  the  muscles  in  the  diseased  process  going  on  in  the  joint,  as 
is  the  case  particularly  in  acute  articular  rheumatism  (Striimpell). 
According  to  Paget,  Hoffa,  and  others,  the  muscular  atrophy  accom- 
panying joint  disease  is  essentially  reflex  in  its  nature — i.  e.,  the  ter- 
minations of  the  nerves  in  the  joints  are  irritated  by  the  inflammation 
going  on  there.  This  irritation  is  carried  centripetally  to  the  ganglion 
cells  in  the  anterior  horns  of  the  grey  matter  in  the  spinal  cord — i.  e.. 


57G     IXJUKIES  AND   SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 

to  the  spinal  centres  of  tlie  nerves  governing  tlie  nutrition  of  the 
atrophying  muscles — and  excites  in  them  certain  changes  which  pro- 
duce the  muscular  atrophy.  The  retlex  atrophy  does  not  take  place 
in  dogs,  for  example,  when  the  knee-joint  is  inflamed,  if  the  posterior 
roots  of  the  third,  fourth,  and  lifth  lumbar  and  first  sacral  nerves  have 
been  divided  (Hoffa,  and  others).  I  share  the  opinion  with  Sulzer, 
Strasser,  and  others,  that  the  muscular  atrophy  in  joint  diseases  is 
mainly  an  atrophy  of  disuse,  and  one  can  often  demonstrate  that  the 
amount  of  atrophy  depends  upon  the  degree  of  mobility  of  the  joint. 
Besides  this  atrophy  of  disuse  the  trophoneurotic  reflex  atrophy  due 
to  the  joint  lesion  also  comes  into  consideration,  particularly  in  the 
wholly  unused  muscles. 

Anatomically,  we  distinguish  the  following  forms  of  muscular 
atrophy : 

1,  Simple  atrophy  of  the  muscular  fibres  ;  2,  atrophy,  with  an  inter- 
stitial growth  of  fat  cells  (lipomatosis  of  the  muscles) ;  and,  3,  degener- 
ative atrophy. 

Simple  Atrophy. — In  simple  muscular  atrophy  followino'  local  or  consti- 
tutional disturbances  of  nutrition,  the  muscular  fibres  decrease  in  size  and 
number,  and  no  other  anatomical  changes  can  be  found.  Atrophy  of  the 
muscular  fibres,  with  a  growth  of  adipose  and  connective  tissue  between 
the  muscular  fibres,  is  frequently  observed.  Generally'  the  growth  of  the  fat 
and  connective-tissue  cells  is  secondary  to  primary  atrophy  and  degeneration 
of  the  muscles.  Occasionally  the  development  of  fatty  tissue  in  tlie  muscle 
is  so  extensive  that  the  latter  increases  in  size.  This  is  the  case  in  the  fol- 
lowing foi'in  : 

Pseudo-hypertrophic  Muscular  Paralysis  (Erb).— This  disease  occurs  almost 
exclusively  in  children,  particularly  boys,  and  consists  in  a  gradually  devel- 
oping simple  atrophy  of  the  muscles,  with  a  secondary  interstitial  growth  of 
fat  cells  (Fig.  3S7),  which  may  become  so  pronounced  that  many  muscles — 
among  others  those  of  the  calf  of  tbe  leg — become  considerably  increased  in 
size.  In  addition  to  these  abnormally  hyj)ertrophied  muscles  thei^e  ai'e  others 
which  are  greatly  emaciated.  The  atrophy  spreads,  and  involves  the  gi'eater 
part  of  the  muscular  system  ;  the  paralysis  of  the  muscles  steadily  increases, 
and  the  patients  become  constantly  more  helpless.  Death  usually  occurs 
within  five  to  ten  to  fifteen  years  from  marasmus  or  from  paralysis  of  the 
muscles  of  respiration.  The  pseudo-b ypertroi)hy  is  a  primary  disease  of  the 
muscles,  and  is  probably  due  to  a  congenital  change  in  the  muscular  tissue, 
which,  at  the  period  when  development  takes  place,  leads  to  a  growth  of  fat 
in  the  perimysium  internum  and  to  atrophy  of  the  muscular  fibres. 

Fatty  Degeneration. — The  fatty  degeneration  of  the  muscular  fibres  be- 
longs to  the  degenerative  atrophies  of  muscle.  In  this  the  primitive  muscu- 
lar fasciculi  change  into  fat  as  a  result  of  inflammatory  processes,  or  inac- 
tivity due  to  jiaralysis.  or  of  trophic  disturbances  due  to  a  degeneration  of 
the  anterior  roots  of  the  spinal  nerves ;  or  it  may  occur  in  connection  with 
an  anchylosis  or  one  of  the  acute  infectious  diseases  (typhoid  fever,  dij)hthe- 


§  98.] 


THE   DISEASES  OP   MUSCLES. 


577 


ria),  or  may  follow  phosphorus  poisoning,  etc.  The  so-called  progressive 
muscular  atrophy  belongs  to  this  group.  The  form  of  progressive  muscular 
atrophy  described  by  Duchenne  and  Aran  is  produced  by  spinal  disturbances, 
while  other  foi-ms  are  dependent  upon  multiple  disease  of  nerves,  or  have 
the  nature  of  primary  muscular  affections.  To  this  latter  class  of  cases  be- 
longs juvenile  muscular  ati^ophy  (Erb),  which  runs  its  course  sometimes  with, 
and  sometimes  without,  lipomatosis.  The  atrophy  of  the  muscles  is,  for  the 
most  part,  primary,  and  as  it  increases  paralysis  gradually  develops.  The 
disease  begins  in  a  particular  group  of  muscles,  often,  for  example,  in  the 


Fig.  387. — Lipomatosis  (pseudo-hypertrophy^i  of  tlii;  muscles.     Development  of  fat  between  the 
muscle  fibres ;  at  a  remnants  of  broken-down  muscle  fibres,      x  200. 


hand  or  the  ball  of  the  thumb.  The  atrophy  then  spreads  intermittently,  and 
in  the  severest  cases  gradually  attacks  the  majority  of  the  muscles.  Progress- 
ive muscular  atrophy  belongs  to  the  domain  of  nervous  diseases,  and  conse- 
quently we  cannot  take  it  up  more  fully  here. 

Waxy  Degeneration  occurs  especially  in  typhoid  and  puei'peral  fevers,  as 
a  result  of  contusions,  in  tetanus,  and  after  the  muscles  have  become  thor- 
oughly tired  out  by  electrical  stimulation  (Roth).  We  have  to  deal  in  this 
condition  with  a  death  of  the  contractile  muscular  substance  and  its  coagu- 
lation into  a  translucent  hyaline  mass. 

Amyloid  Degeneration  of  the  Muscles.— Amyloid  degeneration,  which 
may  involve  the  muscles  of  the  tongue  and  larynx  as  a  result  of  inflamma- 
tory processes,  is  a  very  rare  disease  of  muscle.  According  to  Ziegler,  amy- 
loid degeneration  affects  the  perimysium  interiium  and  sarcolemma,  causing 
Ihem  to  become  thickened  and  present  a  homogeneous  ajDpearance,  while  the 
contractile  substance  disappears. 

'Kypertr O^hj.— Muse nlar  hypertrophy  has  no  practical  interest ;  it  is 
partly  acquired  and  partly  congenital. 

Muscular  Defects. — Congenital  muscular  defects,  which  may  occur  in  the 
pectoralis  major  and  minor  and  in  other  muscles,  should  also  be  mentioned. 

Tumours  of  tnuscles  are  discussed  under  the  subject  of  tumours.  Of 
animal  parasites  which  occur  in  muscles  there  are  the  trichina,  the  Cysti- 
40 


578    INJURIES  AND  SURGICAL  DISEASES  OF  THE  SOFT  PARTS. 

cercus  ceUulosa\  aud  the  echiiiococcus  (see  Regional  Surgery).  Marguet 
states  that  the  echinococcus  is  found  most  fi'equently  in  the  adductors  of  the 
thigli,  in  the  gkittei,  the  quadratus  femoris,  biceps  of  the  arm,  tlie  peetorales, 
the  ti'apezius,  deltoid,  and  muscles  of  the  back  and  abdomen.  They  form 
fluctuating  tumoiu'S  which  should  be  removed  by  extirpation  or  by  incision 
followed  by  sci'aping  them  out.  Actinomycosis  of  muscles  is  described 
in  §  86. 

Inflammations  of  the  Tendons  and  Tendon  Sheaths  may  occur,  in  the 
first  place,  as  an  acute  diy  tenosynovitis  (tenalgia  crepitans),  a  form 
which  corresponds  to  dry  pleurisy  (plem-itis  sicca).  This  is  character- 
ised by  a  deposition  of  fibrin  upon  the  inner  surface  of  the  tendon 
sheath  and  upon  the  surface  of  the  tendon.  As  a  result  of  this  rough- 
ening, when  the  tendon  is  moved  a  soft  crepitation  or  a  grazing  or 
creaking  sound  is  communicated  to  the  hand  held  over  the  inflamed 
region.  This  form  of  tenosynovitis  affects  most  commonly  the  extensor 
tendons  of  the  forearm  in  individuals  who  work  at  heavy  manual  labour ; 
it  may  also  occur  in  the  tendons  of  the  leg  (the  tibiales  and  Achilles 
tendons)  after  a  long  march,  for  example. 

The  treatment  of  tenalgia  crepitans  consists  in  painting  the  parts 
with  tincture  of  iodine,  in  immobilising  them  with  proper  dressings 
(splints,  etc.)  and  applying  moderate  pressure  with  cotton,  and  later  em- 
ploying massage  and  passive  motion.  I  use  massage  as  soon  as  possible. 
Recovery  usually  takes  place  in  one  to  two  to  three  weeks. 

Acute  Suppurative  Tenosynovitis. — Suppurative  inflammation  of  the 
tendons  and  tendon  sheaths  (tenosynovitis  acuta  purulenta)  is  most 
commonly  the  result  of  some  injury  which  has  not  been  treated  anti- 
septically,  or  of  a  suppurative  process  in  the  neighbourhood.  Supj)u- 
rative  inflammation  of  the  tendons  and  tendon  sheaths  has  been  de- 
scribed under  the  subject  of  Cellulitis,  in  §  70,  and  consequently  will 
be  only  briefly  mentioned  here.  In  the  fingers,  especially,  the  so-called 
paronychia  or  felon  easily  spreads  to  the  tendon  sheaths  (panaritium 
tendinosum).  Suppurative  tenosynovitis  is  characterised  by  a  collec- 
tion of  pus  between  the  tendon  and  its  sheath,  and  by  a  cellular  infiltra- 
tion of  the  intrafascicular  connective  tissue.  The  milder  cases,  which 
are  treated  by  incision  and  antiseptic  dressings,  terminate  in  a  resti- 
tutio ad  integrum  ;  in  others,  an  adhesion  of  the  tendon  to  the  tendon 
sheath  or  death  of  the  tendon  take  place. 

The  treatment  of  suppui-ative  tenosynovitis  consists  in  making  an 
incision  at  the  earliest  possible  moment,  followed  by  drainage  and  anti- 
septic dressings.  It  is  a  very  important  matter  to  place  the  diseased 
limb  in  a  suitably  elevated  position.  If  the  hand,  for  example,  is- 
involved,  it  should  be  suspended  vertically  by  means  of  suspension 
splints  (see  Fig.  194).     If  the  suppuration  of  the  tendon  sheaths  i& 


§98.]  THE  DISEASES   OP   MUSCLES.  579 

extensive,  the  same  treatment  should  be  employed  as  was  described 
for  cellulitis  in  §  YO.  The  poultices  which  used  to  be  employed 
have  been  given  up  entirely,  and  the  ice  treatment  is  also  not  very 
effective.  Whenever  it  is  possible,  suppuration  should  always  be 
anticipated,  and  its  extension  should  be  prevented.  If  necrosis  of 
the  tendon  occurs,  care  should  be  taken  to  keep  the  affected  portion  of 
the  limb  in  the  position  in  which  it  will  be  the  most  useful  afterwards. 
The  treatment  of  defects  in  tendons  is  discussed  on  page  482. 

Tuberculosis  of  the  Tendon  Sheaths. — Tubercular  tenosynovitis  occurs 
both  as  a  primary  disease  and  secondary  to  tuberculosis  in  the  neigh- 
bourhood. Primary  tuberculosis  of  the  tendon  sheaths  is  not  so  rare 
as  used  to  be  believed ;  it  develops  occasionally  from  some  traumatism 
(contusion,  sprain).  Tubercular  tenosynovitis  is  characterised  by  the 
formation  of  miliary  tubercles,  greyish-red,  gelatinous  granulation  tis- 
sue, and  in  the  later  stages  by  the  formation  of  caseous  or  suppurat- 
ing masses  which  are  distributed  along  the  tendon.  In  the  benign 
cases  of  tuberculosis  of  the  tendon  sheaths,  Goldmann  states  that  the 
process  is  a  fibrinoid  degeneration,  and  that  cheesy  degeneration  does 
not  occur.  The  fibrinoid  degeneration  often  leads  to  the  formation  of 
rice  bodies — that  is,  the  degenerated  fibrous  and  villous  growths  break 
loose  and  become  free  corpuscles  (corpuscula  oryzoidea),  which  are 
like  grains  of  rice ;  in  this  way  the  so-called  rice-body  hygroma  devel- 
ops (see  page  559).  Konig,  on  the  other  hand,  claims  that  all  rice 
bodies  in  tubercular  joints,  tendon  sheaths,  and  bursfe  are  formed 
from  fibrin ;  some  result  from  clots  of  fibrin  which  are  formed  in  the 
synovial  fluid,  and  others  from  deposits  on  the  wall  of  the  synovial 
cavity  which  have  become  partly  organised  by  the  cells  of  the  latter. 
In  my  opinion  the  rice  bodies  are  formed  in  both  ways,  but  in  the 
great  majority  of  cases  they  are  the  result  of  a  degenerative  process, 
as  described  by  Goldmann,  and  the  formation  of  fibrin  is  usually 
secondary.  Rice  bodies  are  also  formed  in  the  same  way  in  non- 
tubercular  joints,  bursse,  and  tendon  sheaths  (see  also  page  581). 

The  treatment  of  tubercular  tenosynovitis  consists  in  carefully  re- 
moving the  tubercular  deposit  with  the  scissors,  forceps,  and  sharp 
spoon.  I  have  obtained  excellent  results,  and  even  entire  cures,  in 
primary  tuberculosis  of  tendon  sheaths.  Care  must  always  be  taken 
that  every  bit  of  the  diseased  tissue  is  removed.  Iodoform  injections 
which  are  very  efficacious  are  discussed  on  page  429.  Losses  of  sub- 
stance in  tendons  can  be  remedied  as  described  on  page  482. 

Hydrops  Tenovaginalis  {Hygroma  of  the  Tendon  Sheaths). — By  hy- 
groma or  hydrops  tenovaginalis  is  understood  a  cystic  formation  which 
occurs  especially  in  the  tendon  sheaths  of  the  hand,  particularly  in  the 


580     INJrKIES   AND   SURGICAL   DISEASES   OF   THE  SOFT   PARTS. 

palm,  where  it  affects  the  flexor  tendons  beneath  the  anterior  annular 
ligament,  also  in  the  fincfers  and  on  the  dorsum  of  the  hand.  It  con- 
sists  essentially  of  an  abnormal  increase  in  the  secretion  of  the  tendon 
sheath.  Some  hygromata  are,  as  we  have  said,  tubercular  in  their 
origin.  To  avoid  repetition,  we  shall  discuss  hygroma  of  the  tendon 
sheath,  together  with  hygroma  of  bursae,  in  §  99. 

Tumours  of  Tendon  Sheaths. — AVe  shall  return  to  tumours  of  the  ten- 
don sheaths  under  the  subject  of  tumours.  Fibromata,  iibrosarcomata, 
sarcomata  and  lipomata  are  liable  to  occur  in  this  situation.  The  latter 
kind  of  tumour  occasionally  forms  diffuse  growths  (lipoma  arborescens) 
which  are  sometimes  symmetrical. 

Rice  Bodies  in  Tendon  Sheaths. — I  have  already  described  the  forma- 
tion of  rice  bodies  in  tuberculosis  of  tendon  sheaths.  Similar  fibrous 
or  cartilaginous  formations  are  sometimes  observed  in  syphilis,  gout, 
after  injuries,  and  occasionally  without  a  demonstrable  cause.  These 
bodies  sometimes  reach  a  considerable  size,  and  then  resemble  floating 
cartilages. 

Myotomy  and  Tenotomy. — Brief  mention  should  here  be  made  of  the 
subcutaneous  division  of  muscles  and  tendons — subcutaneous  myotomy 
and  tenotomy — an  operation  which  is  often  practised  for  contractures. 
The  operation  is  performed  in  the  following  manner :  The  tenotome, 
a  pointed,  slightly  curved  knife  (see  Fig.  57,  page  71),  is  introduced 
with  antiseptic  precautions,  and  the  muscle  or  tendon — it  may  be  the 
tendo  Achillis  or  contracted  fascia — is  cut  through  subcutaneously. 
The  small  punctured  wound  is  covered  with  an  antiseptic  dressing 
which  exerts  pressure.  The  ga]3  which  forms  between  the  retracted 
ends  of  the  tendon  is  then  filled  in  by  newly  developed  connective  tis- 
sue. The  missing  portion  of  tendon  becomes  entirely  regenerated,  and 
the  muscle  suffers  no  loss  of  function.  The  intervening  portion  of  ten- 
don is  developed  from  the  cellular  sheath,  that  wide-meshed  connective 
tissue  which  partly  envelops  the  tendon  and  is  partly  inserted  upon  it 
by  means  of  bands  (vincula  teudinumi.  The  technique  and  indications 
for  myotomy  and  tenotomy  in  particular  portions  of  the  body  are  dis- 
cussed in  the  Regional  Surgery. 

§  99.  The  Diseases  of  the  Bursae. — The  bursse  mucosae  are  more  or 
less  sharply  defined  connective-tissue  sacs  having  a  smooth  inner 
surface  which  is  covered  with  endothelium,  and,  like  the  joints,  secretes 
synovia. 

Origin  and  Occurrence  of  Bursae.— BursEe,  as  a  rule,  develop  in  places 
where  the  skin,  fascia,  muscles,  etc.,  are  subjected  to  continual  pressure  and 
friction,  particularly  over  bony  prominences.  This  explains  why  the  num- 
ber of  bursEe  is  not  constant,  and  why  bursae  form  in  portions  of  the  body 


§  99.]  THE  DISEASES   OF   THE  BUKS^E.  581 

other  than  where  they  normally  occur  (so-called  accidental  or  supernumerary 
bursa?).  One  may  thus  develop  upon  the  first  metatarsal  bone  in  hallux  val- 
gus, over  the  spinous  processes  in  kyphosis  of  the  vertebrae,  upon  the  sternum 
of  shoemakers,  etc.  Young  children  lack  a  large  number  of  bursse  which 
subsequently  develop  as  the  parts  become  subjected  to  increased  use.  Bursse 
originate  from  the  soft  connective  tissue  which  lies  between  two  layers  of 
tissue,  and  which  becomes  more  and  more  wide-meshed.  The  space  in  the 
tissues  is  at  the  outset  irregular  and  contains  atrophied  connective-tissue 
fibres,  but  it  develops  by  degrees  into  a  complete  sac  with  smooth  walls 
and  endothelium  like  any  other  connective-tissue  space.  The  number  of  the 
more  or  less  constant  bursee  is  very  great.  Gruber  found  eighteen  in  the 
parts  around  the  knee  joint  and  eleven  bursas  musculares  at  the  elbow  joint, 
in  addition  to  the  bursa  anconea  epitrochlearis  and  epicondylica.  Velpeau 
found  fourteen  burscC  on  the  dorsum  of  the  hand,  etc. 

Acute  Inflammation  of  a  Bursa. — The  acute  inflammation  of  a  bursa 
(acute  hygroma,  bursitis  acuta)  is  either  serous,  sero -fibrinous,  or  puru- 
lent. All  cases  of  acute  bursitis  give  rise,  in  consecjuence  of  the  in- 
creased secretion,  to  a  more  or  less  prominent  fluctuating  tumour.  The 
purulent  inflammation  occasionally  takes  on  a  phlegmonous  character, 
causing  the  pus  to  burrow  into  the  neighbouring  cellular  tissue  or  into 
joints,  etc.  The  bursa  most  commonly  inflamed  is  the  bursa  prsepatel- 
laris  (see  Regional  Surgery). 

Chronic  Inflammation  of  Bursse  (Hygroma). — The  most  common  form 
of  the  chronio  inflammation  of  bursee  is  the  hydrops  or  hygroma.  In 
the  majority  of  instances  it  occurs  as  a  painless  fluctuating  tumour,  with- 
out change  in  the  cutaneous  covering.  Its  contents  consist  of  a  thick, 
mucoid  liquid.  The  shape  of  the  tumour  corresponds  to  the  degree  of 
extension  of  the  bursa.  The  hygroma  prsepatellare  is  the  most  com- 
mon of  all  hygromata  of  bursse  (see  Regional  Surgery).  Should  a  com- 
munication exist  between  the  hygroma  and  a  joint,  a  corresponding 
serous  effusion  will  be  found  in  the  latter,  Hygromata  sometimes 
develop  in  connective  tissue  from  fibrinous  exudation  without  the  pre- 
vious formation  of  a  bursa. 

In  other  cases  of  hygroma  the  walls  become  thickened  to  a  greater 
or  less  extent  (fibrous  degeneration),  particularly  if  the  disease  has 
existed  a  long  time,  or  a  villous  growth  takes  place  in  the  bursa  and 
the  villi  may  break  loose  and  form  rice  bodies  (corpuscula  oryzoidea). 
Occasionally  there  will  be  so  many  free  bodies  in  the  hygroma  that  the 
latter  feels  like  a  bag  filled  with  shot  (ganglion  crepitans,  hygroma  pro- 
liferum).  As  already  mentioned  on  page  579,  these  rice  bodies  in 
tubercular  and  non-tubercular  tendon  sheaths,  bursae,  and  joints  result 
in  tlie  main  from  degeneration  of  tissue.  Free  bodies  may  also  be 
formed  by  growths  of  cartilage  which  break  loose  from  the  hygroma. 


582    INJURIES  AND  SURGICAL  DISEASES  OF  THE   SOFT   PARTS. 

The  shape  of  the  hodj  is  round,  elongated,  faceted,  or  hke  a  pear, 
cucumber,  or  melon.  Their  number  varies  greatly,  often  reaching 
many  hundreds. 

The  hygroma  of  the  tendon  sheaths  mentioned  on  page  579  pre- 
sents practically  the  same  manifestations  as  that  of  the  burste. 

A  hyg]"oma  originates  almost  always  from  mechanical  causes,  espe- 
cially from  prolonged  mechanical  irritation,  from  contusions,  sprains, 
etc.  Yolkmann  believes  that  the  rare  cases  of  multiple  hygromata  are 
occasionally  due  to  rheumatic  causes.  Syphilis  and  particularly  tuber- 
culosis also  give  rise  to  the  formation  of  hygromata,  which  in  some 
cases  contain  rice  bodies. 

Part  of  the  proliferating  hygromata  must  be  looked  upon  as  tu- 
mours, some  of  them  being  benign,  endothelial  growths  (Morisani),  and 
others  malignant,  sarcomatous  tumours  (Mikulicz). 

The  best  treatment  of  hygromata  consists  in  puncture  followed  by 
antiseptic  irrigation  with  a  l-to-1,000  solution  of  bichloride  of  mercury 
or  a  three-per-cent.  solution  of  carbolic  acid  ;  or,  better  still,  an  incision 
should  be  made  and  the  hygroma  extirpated  with  antiseptic  precau- 
tions as  completely  as  possible.  The  procedures  which  were  practised 
in  the  days  before  antisepsis  (application  of  the  tincture  of  iodine,  pres- 
sure, etc.)  are  not  sufficient  (see  Regional  Surgery). 

The  treatment  of  acute  inflammation  of  bursse  is  conducted  accord- 
ing to  general  rules.  Painting  the  part  with  iodine,  pressure,  and  mas- 
sage ^vill  often  suffice  for  the  milder  serous  effusions.  If  there  is  a 
violent  inflammation  or  suppuration,  aseptic  incision  is  the  only  proper 
procedure.  In  the  case  of  large,  purely  serous  effusions,  puncture,  with 
or  without  antiseptic  irrigation,  with  a  l-to-1,000  solution  of  bichloride 
or  a  three-per-cent.  solution  of  carbolic  is  usually  sufficient. 

Haematomata  of  the  Bursse. — The  effusion  into  the  bursa  is  bloody, 
when,  as  a  result  of  some  injury,  there  has  occurred  an  extravasation  of 
blood  into  the  bursa,  or  when  traumatic  or  inflammatory  haemorrhages 
have  taken  place  from  the  wall  of  the  hygroma.  The  treatment  of 
these  hsematomata  of  bursas  is  essentially  the  same  as  that  for  pure 
hygromata. 

Ganglion. — The  so-called  ganglion  generally  takes  the  form  of  a 
round,  elastic  tumour,  lying  beneath  the  skin  and  occurring  in  the 
neighbourhood  of  joints,  particularly  those  of  the  hand  and  foot. 
Many  authorities  have  classed  it  with  the  hygromata  of  bursse  and  ten- 
don sheaths,  but  A'olkmann  is  right  in  distinguishing  the  ganglion  from 
these.  He  states  that  the  ganglia  have  a  genetic  connection  with  the 
joint  cavities,  less  often  with  the  tendon  sheaths,  and  are  to  be  regarded 
as  new  growths  in  a  limited  sense  of  the  word.     The  ganglion  origi- 


§  100.]  GANGRENE   (NECROSIS)  OF   THE  SOFT   PARTS.  583 

nates  from  a  pouch-like  appendage  of  the  joint  or  diverticulum  of  the 
synovial  membrane.  The  diverticulum  becomes  filled  with  thickened 
synovia,  and  may  be  completely  cut  off  from  the  joint  by  obliteration 
of  its  pedicle ;  it  practically  becomes  an  independent  cystic  tumour. 
Ganglia  are  to  be  regarded  essentially  as  synovial  hernise.  Less  fre- 
quently they  originate  from  a  kind  of  cystic  degeneration  of  the  cap- 
sule, or  in  other  wounds  from  an  abnormality  in  the  secretion  of  the 
synovia.  There  are,  it  is  true,  intermediate  forms  between  ganglia 
and  hygromata. 

The  treatment  of  ganglia  consists  in  bursting  them  subcutane- 
ously  by  pressure  with  the  finger,  or  by  the  blow  of  a  wooden  ham- 
mer, e,  g.,  upon  a  seal  which  is  enveloped  in  cloth  and  placed  upon 
the  ganglion,  or  in  puncturing  or  incising  the  tumour  subcutaneously 
with  a  tenotome  and  then  applying  a  dressing  which  exerts  pressure, 
Recurrences  are  very  common  after  these  methods  of  treatment. 
Jordan  recommends  the  injection  of  iodine  and  glycerine  (iodine  O.T, 
potassium  iodide  2.0,  glycerine  30.0)  followed  by  massage  and  a  com- 
pressive dressing  after  the  contents  of  the  ganglion  have  been  pre- 
viously removed  by  aspiration.  Out  of  twenty-five  cases  treated  in 
this  way  twenty-four  showed  no  recurrence  after  one  and  three-quarter 
years.  The  surest  and  safest  procedure  is  free  aseptic  incision,  fol- 
lowed by  as  complete  an  extirpation  of  the  ganglion  as  possible.  This 
operative  treatment  is  entirely  devoid  of  danger  if  the  rules  of  antisep- 
sis are  carefully  observed.  (See  also  Regional  Surgery  for  the  treat- 
ment of  ganglion  at  the  wrist.) 

§  100.  Gangrene  (Necrosis)  of  the  Soft  Parts. — When  treating  of  the 
subjects  of  infiammation  and  injuries,  we  showed  that  they  often 
caused  death  of  tissue,  mortification,  necrosis,  or  gangrene.  It  may  be 
well  to  give  at  this  point  a  concise  description  of  gangrene  of  the  soft 
parts  following  inflammation  and  injuries. 

Gangrene  is  to  be  regarded  as  a  disturbance  of  nutrition  arising 
from  local  vascular  changes,  diseases  of  the  nerves,  constitutional  con- 
ditions (syphilis,  alcoholism,  diabetes,  etc.),  from  injuries  to  vessels  or 
nerves,  burns,  freezing,  in  the  course  of  general  (bacterial)  infectious 
diseases  (pysemia,  septicsemia,  typhoid  fever,  etc.),  or  from  severe  local 
inflammations,  such  as  cellulitis,  etc. 

Causes  of  Gangrene. — The  causes  of  tissue  death  are  as  follows :  1.  Inter- 
ruption of  the  afferent  flow  of  arterial  blood  without  the  development  of  a  col- 
lateral circulation,  such  as  may  occur  in  the  case  of  thrombosis  and  embolism, 
or  after  ligation,  or  in  consequence  of  the  pressure  of  a  tumour  or  inflamma- 
tory exudate.  2.  Interruption  of  the  efferent  flow  of  venous  blood.  3.  Inter- 
ruption or  stasis  of  the  circulation  in  the  capillai'ies,  as  a  result  of  pressure, 


584    INJURIES  AND   SUliGICAL   DISEASES  OP   THE   SOFT   PARTS, 

coagulation  of  the  contents,  or  disease  of  the  capiHary  walls.  4.  Death  of 
the  tissue  cells  without  any  disturbance  of  circulation,  due  to  poisons,  such 
as  a  snake  bite,  or  to  inicro-organisms  and  the  products  of  their  metabolism, 
such  as  are  found  in  infectious  diseases  of  wounds — for  example,  erysipelas, 
cellulitis,  septiccemia,  etc.  The  various  causes  of  gangrene  are  frequently 
more  or  less  combined — for  example,  abnormally  high  or  low  tempera- 
tures cause  both  the  cells  and  the  vessels  to  lose  their  integrity  in  con- 
sequence of  the  coagulation  of  the  albumen.  The  different  tissues  possess  dif- 
ferent powei'S  of  resistance  against  the  above-mentioned  causes  of  gangrene. 
A  loop  of  intestine,  for  example,  will  die  if  exposed  for  a  couple  of  hours  to 
a  temperature  of  8°  to  10°  C.  (45°  to  50°  F.),  while  muscles  or  tendons  will  be 
but  little  or  not  at  all  affected  from  a  similar  exposure  to  the  same  influences. 
The  brain,  kidneys,  and  intestine  undergo  necrosis  within  one  or  two  houi^s 
after  interruption  of  the  afferent  fl.ow  of  blood,  while  the  skin  and  muscles 
can  do  without  circulation  for  ten  or  twelve  hours.  The  tissues  present 
these  same  differences  when  subjected  to  traumatisms.  The  brain  is  very 
susceptible  to  traumatic  influences,  and  likewise  to  loss  of  water,  while  the 
skin,  connective  tissue,  and  bone  are  much  less  so. 

Local  and  general  anaemia,  venous  stasis,  distui'bances  of  circulation 
from  diseases  of  the  vessels,  heart,  or  lungs,  or  disturbance  of  circulation  due 
to  inflammation — in  short,  faulty  circulation  from  any  cause — increases  the 
disposition  to  gangrene  from  the  effects  of  mechanical,  chemical,  or  thermal 
influences.  Under  these  conditions,  comparatively  slight  causes  may  suffice 
to  bring  about  death  of  tissue. 

Senile  Gangrene. — Gangrtena  senilis  belongs  to  this  class  of  cases ;  it  is  a 
mortification  occurring  in  old  age  and  affecting  the  toes  especially.  There 
is  usually  an  accompanying  advanced  arterio-sclerosis  with  chronic  dis- 
turbances of  the  circulation,  and,  following  some  mild  inflammation  or 
slight  traumatism,  complete  stasis  takes  place  from  coagulation  of  the  blood 
in  the  capillaries. 

Decubitus. — The  bedsore,  or  decubitus,  originates  from  .some  slight  injury, 
particularly  in  patients  who  are  paralysed;  also  in  the  course  of  severe 
febrile  constitutional  diseases,  and  in  individuals  with  cardiac  and  pulmo- 
nary diseases  which  give  rise  to  stases.  Those  regions  are  particularly 
endangered  where  the  skin  is  directly  superimposed  upon  bone,  as  in  the 
region  of  the  sacrum,  the  great  trochanter,  scapula,  olecranon,  and  heel.  Por- 
tions of  the  body  where  skin  presses  against  skin,  as  in  the  scrotum  or  labia, 
have  but  little  power  of  resistance  in  individuals  with  circulatory  disturb- 
ances. 

In  still  other  instances  a  weak  constitution — in  other  words,  a  condition 
in  which  the  cells  possess  slight  powers  of  resistance — favours  the  occurrence 
of  gangrene.  This  is  seen  in  old  people  with  advanced  arterio-sclerosis  and 
in  those  who  are  poorly  nourished. 

Noma. — This  is  the  reason  why  the  gangrene  which  spreads  so  rapidly  on 
the  face,  the  so-called  cancrum  oris,  or  noma  (Fig.  388).  is  particularly  likely 
to  develop  in  individuals  who  are  very  much  reduced  and  in  children  after 
acute  infectious  diseases  (see  Regional  Surgery). 

Ergotine  Gangrene. — Poorly  nourished  individuals  are  the  ones  most  com- 
monly affected  by  the  gangrene  occurring  in  chronic  ergotism,  which  was. 


§100.]  GANGRENE  (NECROSIS)  OF   THE  SOFT  PARTS. 


585 


The  disease  results  from  the  ingestion 
Ergotism  is  charactei-ised  by  disorders 


not  uncommon  in  the  middle  ages, 
of  bread  containing  the  ergot  of  rye 
of  digestion,  by  general 
weakness,  formication, 
numbness,  and  pains 
in  the  extremities,  etc. 
Then  a  rapidly  spread- 
ing gangrene  makes  its 
appearance,  involving 
particularly  the  toes, 
and  whole  portions  of 
the  extremities,  tiie 
ears,  or  nose,  may  per- 
ish. The  main  cause 
of  this  disease  is  prob- 
ably the  contractions 
excited  in  the  small 
arteries  by  the  ergo- 
tine.  This  produces 
anaemia  with  subse- 
quent gangrene,  espe- 
cially if  the  individual 
is  badly  nourished  and 
marasmic.  According 
to  Zweifel,  ergotine 
gangrene  is  mainly  to 
be  ascribed  to  the  anaes- 
thesia caused  by  the  er- 
gotine, in  consequence 
of  which  injurious  in- 
fluences of  all  kinds, 
such  as  traumatisms, 
are  not  perceived,  and  hence  the  individuals  affected  by  the  disease  are 
unable  to  protect  themselves. 

Gangrene  accompanying  an  Abnormal  Composition  of  the  Blood.— Men- 
tion should  be  made  of  the  gangrene  occurring  when  the  composition  of  the 
blood  becomes  altered,  as  in  anaemia,  hydrtemia,  and  diabetes  mellitus.  In 
the  latter  disease  gangrenous  inflammations,  particularly  of  the  cellular  tis- 
sue, are  apt  to  arise  after  the  reception  of  slight  injuries.  As  a  result  of  the 
abnormal  composition  of  the  blood,  the  walls  of  the  vessels  and  the  cells 
have  so  little  power  of  resistance  that,  when  subjected  to  any  slight  trauma- 
tism or  infection,  disturbances  of  circulation  with  stasis  and  gangrene  readily 
develop.  A  diabetic  cellulitis  often  runs  its  course  without  marked  swelling 
or  hyperaemia,  and  there  may  be  no  fever.  Diabetic  gangrene  in  the  vast 
majority  of  instances  is  caused  by  arterio-sclerosis  of  the  vessels,  as  in  senile 
gangrene  (Heidenhain). 

Nervous  Gangrene. — Disturbances  in  the  nerve  supply  may  also  favour 
the  development  of  gangrene.  This  is  the  explanation  of  the  gangrene 
accompanying  leprosy  (§  85),  and  also  that  affecting  paralysed  portions  of 


Fig, 


388. — Noma  iu  a  boy  seven  and  a  half  years  of  age,  four 
weeks  after  tlie  commencement  of  scarlet  fever.  Death  on 
the  twelfth  day. 


586    INJURIES  AND  SURGICAL   DISEASES  OF   THE  SOFT   PARTS. 

the  body.  Either  the  trophic  nerves  lose  their  integrity,  or  the  neci'osis  of 
tissue  and  ulceration  take  place  because  tlie  ])atients  do  not  feel  the  irritations 
of  the  skin,  and  thus,  as  in  ergotism,  cannot  avoid  the  injurious  etfects  of 
such  irritation. 

The  so-called  malum  perforans  pedis,  a  punched-out,  pi'ogressive  ulcera- 
tion of  the  sole  of  the  foot,  and  the  symmetrical  gangrenes,  are  likewise  due 
to  nervous  causes. 

Symmetrical  Grangrene. — According  to  Raynaud  and  "Weiss,  symmetrical 
o-ano-rene  usually  appears  in  paroxj'sms,  affecting  the  fingei'S,  toes,  and  less 
often  other  portions  of  the  body.  This  rare  disease  begins  with  i^ara^sthesia 
and  neuralgic  pains ;  then  cyanosis  or  angemia  develops  in  the  parts  which 
are  involved  in  consequence  of  contraction  of  the  vessels.  The  gangrene 
generally  begins  in  the  pulp  of  the  terminal  phalanx,  and  either  remains 
superficial  or  the  entire  terminal  phalanx  perishes.  Bi-amann  saw  this  sym- 
metrical gangrene  develop  in  three  brothers  of  seven,  ten,  and  thirteen  yeai-s 
of  age  ;  it  was  probably  the  result  of  syringomyelia.  As  etiological  factors, 
chlorosis,  anaemia,  hysteria,  acute  febrile  infectious  diseases  (typhoid,  inter- 
mittent fever,  etc.),  or  primary  neuritis,  come  into  consideration.  The 
direct  cause  of  this  form  of  gangrene  is  to  be  sought  probably  in  disturbances 
of  the  vasomotor  centres  in  the  central  nervous  system.  The  acute  gangrene, 
originating  from  disease  of  the  vessels,  is  certainly  to  be  distinguished  from 
the  purely  nervous  symnietrical  gangrene  fSocin). 

Spontaneous  (Angionenroticj  Gangrene  of  the  Extremities  occurring  in 
Youth.— In  rare  instances  a  spontaneous  gangrene  of  the  extremities  is 
observed  which  is  not  due  to  ergotism,  diabetes,  or  syijhilis.  and  which,  in 
contradistinction  to  senile  gangrene,  affects  strong,  young  individuals  who 
are  not  marasmic  (Billrotli.  Braun,  etc.).  The  course  of  the  disease  is  very 
tedious  and  extremely  painful.  In  rare  cases  spontaneous  recovery  has  been 
observed,  but  it  is  generally  the  best  plan  to  amputate  the  limb,  for  example, 
by  Gritti's  method,  at  the  knee,  or  higher  up,  through  the  thigh.  Attempts 
at  amputation  nearer  the  periphery,  in  close  proximity  to  the  gangrene,  are 
usually  hopeless.  Zoege-Manteuffel  and  others  found  the  causation  of  this 
spontaneous  gangrene  to  be  a  high  grade  of  arterio-sclerosis,  with  narrowing 
and  thrombosis  not  only  of  the  main  arterial  trunks  in  the  leg,  but  also  of 
the  smaller  veins.  The  lesions  consist  of  a  narrowing  or  closure  of  the  ves- 
sels either  by  an  endarteritis  obliterans  due  to  proliferation  of  the  endothe- 
lium with  hypertrophy  of  the  muscular  coat,  or  by  organised  clots  in  the 
vessels  which  have  been  formed  in  consequence  of  the  arterio-sclei'osis.  The 
principal  nerves  are  usually  much  thickened  and  swollen.  This  sclerosis  of 
the  vessels  is  probably  a  trophic  disturbance  of  the  latter  dv;e  primarily  to 
lesions  of  the  nervous  system.  Angio-sclerotic  gangrene  is  particularly  apt 
to  occur  in  cold,  northern  regions,  such  as  Russia.  In  other  cases  the  chronic 
diseases  of  the  walls  of  the  blood-ves.se] s  resulting  in  gangrene  are  caused  by 
syphilis,  old  age.  diabetes,  alcoholism,  lead-poisoning,  etc. 

Symptoms  of  Gangrene. — The  symptoms  of  gangrene  vary  in  general 
according  to  its  cause  and  location,  as  well  as  the  kind  of  tissue  which  is 
affected.  We  recognise  a  diy  gangrene — mummification,  as  it  is  called — and 
a  moist  gangrene.  In  dry  gangrene  there  is  dryins"  of  the  tissues  as  a  result 
of  a  loss  of  water  ;  senile  gangrene  is  an  example  of  this  form.     In  such  cases 


§  100.]  GAXGRENE   (KECROSIS)   OP   THE   SOFT   PARTS.  587 

the  superficial  layers  of  tissue  dry  and  form  a  gangrenous  eschar.  The  moist 
gangrene  is  a  necrosis  with  softening  and  liquefaction,  and  consequently  is 
the  opposite  of  dry  gangrene.  Moist  gangrene  is  particularly  likely  to  be 
accompanied  by  decomposition.  In  such  cases  the  tissues  are  softened  and 
discoloured,  and  present  bluish-red,  green,  or  black  spots  ;  they  give  forth  a 
penetrating  odour,  which  is  due  to  the  formation  of  products  consisting  of 
compounds  of  ammonia  and  fatty  acids.  The  epidermis  is  elevated  by  blebs 
which  are  filled  with  a  stinking  liquid.  Not  infrequently  bubbles  of  gas 
develop  at  the  same  time  which  contain  especially  ammonia,  volatile  fatty 
acids,  and  sulphide  of  hydrogen.  Finally  the  tissues  break  down  and  form 
discoloured,  shreddy  masses.  This  moist  gangrene  with  decomposition  is 
particiilarly  apt  to  take  place  when  the  air  with  its  germs  has  access  to  the 
parts  and  no  disinfecting  antiseptic  dressing  is  employed,  and  consequently 
occurs  most  commonly  in  the  superficial  portions  of  the  body  and  the  cavi- 
ties which  adjoin,  in  the  lungs,  etc.  It  is  only  possible  for  this  gangrene  to 
attack  other  organs  by  metastases,  which  are  caused  by  suppurating  thrombi 
or  gangrenous  pus  and  the  bacteria  they  contain. 

The  coagulation  death  is  another  form  in  which  gangrene  presents 
itself.  It  occurs  especially  in  necrosis  of  the  muscles  or  other  tissues  made 
up  of  cells  containing  protoplasm  which  is  capable  of  coagulation.  Accord- 
ing to  Cohnheim  and  Weigert,  it  is  dependent  either  upon  a  chemical  pre- 
cipitation of  an  albuminate  or  upon  coagulation  of  the  albumen  by  the 
action  of  a  ferment  which  is  set  free.  Coagulation  necrosis  occurs  par- 
ticularly in  diphtheria,  croup,  and  in  the  tissues  surrounding  colonies  of 
bacteria. 

Cohnheim  states  that  necrosis  very  seldom  results  from  the  action  of 
moulds,  for  the  reason  that  the  mould  fungi  and  the  bacteria  of  decompo- 
sition do  not  exist  under  the  same  conditions.  A  medium  which  supports 
the  bacteria  of  putrefaction  is  unsuitable  for  mould  fungi.  The  latter,  for 
the  most  part,  are  incapable  of  development  in  the  living  body,  and  soon 
disappear  (see  pages  257-259). 

Other  symptoms  of  gangrene  are  a  loss  of  function  in  the  parts  affected, 
their  insensibility,  and  the  cool  or  cold  feeling  which  they  exhibit  on  pal- 
pation. 

The  microscopic  changes  in  the  dead  tissues  vary  with  the  form  of  the 
necrosis — that  is,  whether  they  become  dry  or  undergo  putrefaction.  In  the 
above-mentioned  coagulation  neerosis  of  Weigert  the  cell  nuclei  disappear 
first.  The  nuclei  are  dissolved  by  the  lymph,  and  the  substance  of  which 
they  consist  perhaps  unites  with  the  albuminous  constituents  of  the  lymph. 
This  phenomenon  is  similar  to  the  coagulation  of  fibrin.  The  dead  cells  also 
exhibit  a  diminution  in  the  size  of  the  nuclei,  vacuolar  degeneration,  swell- 
ing of  the  protoplasm  of  the  cell,  and  a  merging  of  the  borders  of  the  cells 
into  the  surrounding  parts. 

As  regards  the  course  of  the  gangrene,  it  either  remains  limited  to  a  par- 
ticular region,  or  it  spreads.  The  gangrene  following  an  interruption  of  the 
circulation  or  some  direct  traumatic  disturbance  of  the  tissue  elements  in  an 
otherwise  healthy  individual,  ordinarily  remains  circumscribed  unless  the 
gangrenous  focus  becomes  infected  by  bacteria.  On  the  other  hand,  if  the 
health  of  the  individual  or  of  the  affected  portion  of  the  body  is  faulty,  the 


5SS    INJURIES  AND  SURGICAL    DISEASES  OF   THE  SOFT   PARTS. 

gangrene  may  spread  (decubitus,  senile  gangi-ene,  diabetes  niellitus).  The 
gangrene,  in  particular,  which  follows  the  development  of  bacteria,  is 
ver}-  prone  to  spread  (.see  pages  339-344).  The  boundarj-  of  the  necrosed  tis- 
sue is  formed  by  the  so-called  line  of  demarcation — that  is,  by  a  demarcat- 
ing inflammation  and  suppuration — by  which  the  living  are  separated  from 
the  dead  parts.  A  loss  of  substance  takes  place— in  other  words,  an  ulcer  of 
the  skin,  the  surface  of  the  ulcer  being  the  seat  of  a  suppurative  inflamma- 
tion. This  ulcer  gi-adually  purifies  itself  and  cicatrises  by  the  formation  of 
granulation  tissue.  Not  infrequently  when  the  dead  tissue  is  cast  ott',  some 
cavity  of  the  body  is  opened,  and  death  follows.  Thus,  for  example,  perfora- 
tion of  the  intestine  or  stomach  by  an  ulcer  may  give  rise  to  fatal  peritonitis, 
and  caries  and  necrosis  of  the  petrous  portion  of  the  temporal  bone  may  cause 
suppurative  meningitis  or  a  cei-ebral  abscess.  Other  dangers  of  gangrene  are 
the  occurrence  of  hcemorrhage  from  the  erosion  of  an  artery,  and  tlie  devel- 
opment of  some  secondary  infectious-wound  disease,  particularly  pya?mia 
and  septicaemia,  from  infection  by  micro-organisms  and  the  products  of  their 
metabolism. 

The  treatment  of  gangi'ene  is  conducted  according  to  the  rules  laid  down 
in  §§  70,  88,  and  90  to  98,  to  which  we  must  refer  the  reader.  In  gangrene  of 
the  extremities,  amputation  should  not  be  performed  too  near  the  gangrenous 
parts — a  matter  which  has  been  insisted  upon  before.  Should  a  gangrene  of 
the  foot,  for  example,  involve  the  dorsum  or  sole,  Gritti's  operation  should 
be  given  the  preference,  or  amputation  at  the  thigh,  because,  if  the  leg  is 
amputated  below  the  knee,  extensive  gangrene  of  the  flaps  almost  always 
occurs.  Occasionally,  however,  amputation  two  to  three  fingers"  breadth 
above  the  gangrene  is  followed  by  good  results  (Konig,  Landowj. 


CHAPTEE  III. 

INJURIES    AND    SITRGICAL    DISEASES    OF   BONE. 

Injuries  of  bones :  Fractures ;  contusions  and  wounds  of  bone ;  gunshot  injuries  of 
bone  (see  also  §  124). — The  inflammations  and  diseases  of  bone  :  Acute  inflamma- 
tions of  bone  ;  acute  periostitis ;  acute  osteomyelitis ;  acute  ostitis. — Metastatic 
inflammations  of  bone. — Embolic  foreign-body  inflammations  in  mother-of-pearl 
turners  and  workers  in  woollen  and  jute  mills. — The  chronic  inflammations  of 
bone  (tuberculosis,  syphilis,  etc.) :  Chronic  periostitis,  osteomyelitis,  and  ostitis. — 
Caries. — Necrosis  of  bone. — Spontaneous  separation  of  an  epiphysis. — Rhaehitis. — 
Osteomalacia. — Atrophy  and  hypertrophy  of  bone. — Increased  longitudinal  growth. 
— Giant  growth. — Acromegaly. — Tumours  of  bone  (see  Tumours,  Chapter  V). — 
Parasitic  tumours  of  bone  (echinococcus ;  cysticercus  cellulosce). 

§  101.  Fractures. — The  word  fracture  needs  no  further  definition  ; 
it  means  both  the  act  of  breaking  a  bone  and  the  state  of  being  broken. 
Fractures  are  very  common,  and,  according  to  Brans,  they  make  up 
more  than  a  seventh  part  of  all  injuries  which  come  under  observa- 
tion, and  are  about  ten  times  as  common  as  dislocations. 

Causes  of  Fractures. — Every  fracture  presupposes  the  action  of  some 
mechanical  violence  upon  the  bone  in  question  which  is  great  enough 
to  overcome  the  strength  and  the  power  of  resistance  which  the  bone 
possesses.  The  majority  of  fractures  are  produced  by  external  vio- 
lence ;  and,  according  to  the  way  in  which  the  external  violence  acts, 
we  distinguish  two  main  groups,  the  direct  and  the  indirect  fractures. 

Direct  and  Indirect  Fractures. — The  direct  fractures  are  those  in 
which  the  bones  are  broken  at  the  point  where  the  violence,  such  as  a 
blow,  a  thrust,  a  gunshot,  the  wheel  of  a  wagon,  etc.,  is  applied.  If, 
on  the  other  hand,  the  break  is  situated  at  a  point  some  distance  from 
the  place  where  the  violence  has  ])een  applied — in  a  fall,  for  example — 
we  call  such  a  fracture  an  indirect  one.  It  is  evident  that  in  the  direct 
fractures  especially  the  soft  parts  will  receive  more  or  less  injury, 
which  varies  from  a  slight  contusion  to  a  complete  mangling  of  all  the 
soft  parts  surrounding  the  broken  bone.  The  indirect  fractures  are 
most  commonly  the  result  of  a  bending  of  the  bone  beyond  the  limits 
of  its  elasticity  by  bringing  the  two  ends  of  the  bone  nearer  together, 
as  in   a  fracture  of  the  thigh  from  a  fall  upon  the   feet.     In    other 

589 


590  INJURIES  AND  SURGICAL   DISEASES  OF   BONE. 

instances  indirect  fractures  are  the  result  of  forced  compression  and 
crushing,  as  in  fractures  of  the  vertebrae  from  a  fall  upon  the  buttocks; 
or  of  violence  applied  through  a  fulcrum  with  crushing,  as  in  fracture 
of  the  olecranon  by  hyperextension  at  the  elbow  joint ;  or  of  traction, 
tearing,  or  rotation  (torsion).  The  lower  end  of  the  radius,  for 
example,  is  caused  to  break  by  the  traction  exerted  by  the  anterior 
ligament  of  the  wrist  in  forced  dorsal  flexion.  Great  interest  attaches 
to  the  production  of  indirect  fractures  of  the  skull  by  a  tearing  apart 
of  the  portions  which  are  put  on  the  stretch,  or  by  the  vertebrae  being 
driven  ii^to  the  occipital  foramen  (Messerer).  In  indirect  fractures 
it  sometimes  happens  that  the  fragments  are  more  or  less  firmly  forced 
into  one  another  (so-called  impacted  fractures).  The  injuries  to  soft 
parts  occurring  in  indirect  fractures  are  produced  by  more  or  less 
pointed  fragments  which  perforate  the  skin  (transfixion  fractures),  or 
wound  muscles,  vessels,  or  nerves,  etc. 

Fractures  resulting  from  Muscular  Action. — Sometimes  fractures  are 
the  result  of  excessive  muscular  action.  These  usually  take  the  form 
of  a  tearing  off  of  some  small  bony  pi'ominence,  like  the  coracoid  pro- 
cess of  the  scapula,  or  the  greater  tuberosity  of  the  humerus.  The 
fractures,  which  often  complicate  dislocations,  are  frequently  produced 
in  a  similar  manner  ;  for  example,  the  ilio-femoral  ligament  may  tear 
off  a  piece  of  bone  from  the  femur  at  its  point  of  attachment  (cortical 
fracture).  It  only  rarely  happens  that  large,  hollow  bones  are  broken 
by  muscular  traction.  In  this  category  come  the  fractures  of  the  femur 
sustained  in  playing  at  ninepins,  or  in  administering  a  kick  which 
misses  its  object ;  also  fractui-es  of  the  humerus  from  violent  move- 
ments of  the  arm,  transverse  fi-actures  of  the  patella  (see  Regional 
Surgery),  and  fractures  of  the  clavicle  from  brandishing  a  whip,  or 
fractures  of  the  ribs  as  a  result  of  violent  attacks  of  coughing  in  old 
people,  etc. 

Intra-uterine  Fractures. — Intra-uterine  fractures  in  the  foetus  are  pro- 
duced by  the  inflictiou  of  great  violence  to  the  abdomen  of  the  mother. 
Varying  with  the  length  of  time  which  elapses  between  the  reception  of  the 
injury  and  the  birth  of  the  child,  the  fracture  will  be  found  to  be  compara- 
tively recent,  in  process  of  repair,  or  already  healed.  The  bending  or  frac- 
ture of  bones  due  to  foetal  rhachitis  or  syphilis  are  not  of  traumatic  origin. 
Other  intra-uterine  bony  deformities  are  also  met  with  which  at  first  sight 
look  like  badly  united  intra-uterine  fractures,  but  are,  in  reality,  defects  in 
development.  In  this  class  of  cases  belong  the  malformations  which  are  the 
result  of  defects  in  ossification,  such  as  absence  of  the  fibula,  etc. 

Fractures  during  Birth. — In  other  instances  infants  sustain  fractures 
during  birth  from  unskilful  operative  midwifery  or  from  the  act  of  parturi- 
tion itself.     The  bones  of  the  extremities  may  be  broken  through  the  diaphy- 


§  101.]  FRACTURES.  591 

sis  or  in  the  region  of  the  epiphysis  while  an  arm  is  being-  freed  or  version  or 
extraction  performed,  but  fractm'es  of  the  bones  of  the  head  are  mainly  due 
to  the  use  of  tbe  foi^ceps.  In  very  rare  cases  fractures  of  malposed  extremi- 
ties result  from  contractions  of  the  uterus.  The  latter  are  more  likely  to  cause 
injuries  to  the  skull,  especially  in  cases  of  narrow  pelvis  or  anomalies  of  the 
child's  head.  In  the  milder  cases  there  will  be  a  depression  with  or  without 
fissure,  while  in  severe  cases  actual  fractures  of  the  skull  occur. 

The  amount  of  resistance  of  which  a  bone  is  capable  bears  a  very- 
important  relationship  to  the  production  of  fractures.  The  strength  of 
a  bone  varies  greatly  in  different  individuals,  as  does  also  the  strength 
of  different  bones  in  the  same  individual,  and  even  different  parts  of 
the  same  bone  exhibit  variations  in  resisting  power. 

Natural  Solidity  of  the  Bones. — The  natural  strength  and  mechanical 
capabilities  of  bones,  so  important  in  the  etiology  of  fractures,  have  re- 
cently been  investigated  by  P.  Bruns,  Eeiff,  and  others,  and  the  attempt 
has  been  made  to  found  the  etiology  of  fractures  upon  a  physical  basis. 
The  elasticity  of  the  individual  bones — i.  e.,  their  ability  to  resume  their 
original  shape  after  it  has  been  changed  by  external  force,  and  the  limits 
within  which  this  is  possible— in  other  words,  the  limit  of  their  elas- 
ticity— have  been  computed.  The  strength  or  the  resistance  which  the 
bones  offer  to  violence  in  its  various  forms,  such  as  pressure,  traction, 
bending,  rotation,  or  torsion,  had  also  been  ascertained.  It  has  thus 
been  possible  to  determine  definite  values  for  the  elasticity  and  solidity 
of  the  texture  of  the  bone  substance,  and  for  the  bones  in  their  en- 
tirety, which  values  express  the  amount  of  this  or  that  kind  of  violence 
required  to  produce  fractures ;  and  hence  it  is  perfectly  correct  to 
designate  fractures  according  to  the  nature  of  the  traumatism,  as  frac- 
tures from  traction  or  tearing,  from  compression,  bending,  or  torsion. 

Measurements  showing  the  Strength  of  Bones.— As  regards  the  strength 
of  a  bone  due  to  its  structure,  the  values  naturally  vary  in  different  bones 
and  in  different  individuals',  but  the  general  rule  holds  that  the  compact  bone 
substance  is  always  stronger  than  the  spongy. 

The  tensile  strength  of  the  compact  bone  substance  in  a  fresh  condition 
and  during  middle  life  amounts,  according  to  Rauber  and  Messerer,  to  9.25 
to  13.21  kilogrammes  per  square  millimetre,  or  about  the  same  as  that  of 
brass  and  cast  iron.  The  compression  strength  is  still  greater  (12.56  to  16.8 
kilogrammes  per  square  millimetre),  or  double  that  of  wood,  granite,  or  lead. 
The  torsion  strength  averages  8  kilogrammes  per  square  millimetre. 

The  strength  of  spongy  bone  substance  is  much  less,  the  compression 
strength  of  the  spongy  portion  of  the  femoral  condyles  amounting,  according 
to  Messerer,  to  only  0.96  kilogramme  per  square  millimetre,  that  of  the  bodies 
of  the  vertebrae  to  0.84,  being  in  middle  life  0.62  to  0.92,  and  in  old  age  only 
0.22  kilogramme  per  square  millimetre. 

The  strength  of  the  bone  as  a  whole  is  a  matter  of  great  practical  impor- 
tance as  regards  the  etiology  of  fractures.     The  tensile  strength  of  the  hu- 


592  INJURIES  AND  SURGICAL   DISEASES   OF   BoNE. 

merus,  for  example,  according  to  Messerer,  amounts  to  533,  and  of  tlie  femur 
to  694  kilograinmes  per  square  millimetre.  He  found  that  the  compression 
strength  of  the  individual  bones  decreased  in  the  following  order :  Tibia, 
femur,  humerus,  radius,  ulna,  clavicle,  fibula.  Compression  directed  through 
the  longitudinal  axis  caused  fracture  of  the  shaft,  the  tibia  being  the  strongest 
and  breaking  under  a  pressure  of  1,650  kilogrammes,  the  femur  on  the  aver- 
age in  man  requiring  a  pressure  of  756  kilogrammes,  the  radius  in  man  334 
kilogrammes,  in  women  220  kilogrammes.  Frequently  the  break  does  not 
take  place  at  the  point  most  endangered — the  middle  of  the  bone — but  at  one 
or  other  articular  extremity  by  compression. 

A  great  number  of  fractures  are,  as  is  well  known,  the  result  of  bend- 
ing (Bruns).  The  limit  of  bending  possessed  by  bones  varies  in  different 
years  of  life,  and,  according  to  Messerei*,  it  amounts  to  between  1,040  and 
1,980,  and  reaches  its  maximum  at  middle  age.  In  men  400  kilogi-ammes, 
and  in  women  263  kilogrammes,  will  cause  a  fracture  of  the  femur  from 
bending. 

The  torsion  elasticity  amounts  to  about  a  third  of  the  bending  elasticity. 
A  fracture  of  the  femur  by  torsion,  according  to  Messerer,  is  produced  by  89 
kilogrammes,  of  the  clavicle  by  8  kilogrammes.  The  femur  possesses  the 
greatest  torsion  strength,  the  clavicle,  ulna,  and  fibula  the  least. 

Messerer's  experiments  on  the  skull  show  that  the  diameter,  which  is  not 
subjected  to  pressure,  becomes,  in  the  majority  of  instances,  gradually  though 
very  slightly  lengthened  in  proportion  as  the  pressure  increases.  The  de- 
crease of  the  diameter  in  the  direction  of  the  pressure  is  not  evenly  distributed 
over  the  whole  skull,  as  only  the  part  directly  subjected  to  pressure  bends 
inwards.  The  skull  withstands  a  greater  amount  of  force  in  a  sagittal  than 
in  a  transverse  direction.  The  pressure  required  to  produce  a  longitudi- 
nal fracture  averaged  650  kilogrammes ;  for  a  transverse  fi-acture,  520  kilo- 
grammes. In  most  instances  the  base  of  the  skull  proved  to  be  the  weak- 
est spot,  that  portion  of  it  bursting  which  was  under  the  greatest  tension ; 
transverse  pressure  caused  a  transverse  fracture,  and  longitudinal  pressure  a 
longitudinal  fracture.  The  average  jDressure,  acting  through  the  vertebral 
column,  which  was  required  to  produce  a  fracture  of  the  base  amounted  to 
270  kilogrammes. 

In  young  persons  the  sternum  could  be  driven  completely  back  to  the 
vertebral  column  by  sagittal  j^ressure  upon  the  thorax  without  producing  a 
fracture.  A  pressure  of  250  kilogrammes  exerted  in  a  sagittal  direction  upon 
the  pelvis  generally  caused  a  symmetrical  fracture  of  the  os  pubis  ;  a  trans- 
verse pressure  of  180  kilogrammes  exerted  upon  the  crest  of  the  ilium  caused 
a  diastasis  of  the  sacro-iliac  joint. 

According  to  Rauber,  the  strength  of  bones  is,  as  a  general  thing,  dimin- 
ished by  heat. 

Changes  in  the  Strength  of  the  Bones. — The  normal  strength  of  bones 
is  affected  very  niateriallj  by  various  circumstances,  such  as  their  shape, 
their  length  and  thickness,  the  direction  of  their  longitudinal  axes, 
whether  the  latter  approach  the  perpendicular  or  show  deviations 
from  it,  etc.  There  are  also  various  pathological  conditions  which 
lessen  the  resisting  powers  of  bones  and  produce  an  aljnormal  fragility 


■§  101.]  FRACTURES.  593 

'(osteopsathyrosis),  causing  the  bones  to  break  spontaneously  or  upon 
"the  application  of  a  very  slight  amount  of  violence.  In  this  category 
belongs  the  atrophy  of  bone  which  occurs  in  advanced  age,  or  in  the 
course  of  chronic  diseases,  or  after  paralysis,  etc.  The  strength  of  the 
bones  usually  increases  till  middle  life,  and  from  then  on  gradually 
■decreases  (senile  atrophy).  The  bones  also  atrophy  when  they  are  not 
used,  as  in  the  course  of  chronic  diseases,  in  paralysis,  etc.  (atrophy  of 
disuse). 

Neurotic  or  Trophoneurotic  Atrophy. — In  addition  to  the  atrophies 
of  senility  and  disuse,  Weir  Mitchell,  Charcot,  and  P.  Bruns  have  di- 
rected attention  to  the  occurrence  of  neurotic  or  trophoneurotic  atro- 
phies of  bone  which  are  due  to  affections  of  the  central  nervous  system. 
In  this  class  of  cases  belongs  the  fragility  of  bone  which  accompanies 
tabes  dorsalis  and  chronic  cerebral  disease,  such  as  progressive  paralysis, 
and  in  fact  all  forms  of  mental  disease  and  paralysis.  Rauber  found 
that  the  tibia  of  a  paralysed  extremity  weighed  198  grammes,  while  the 
bone  on  the  non-paralysed  side  weighed  281  grammes.  Nasse,  Schiff, 
and  others  have  seen  very  different  effects  upon  the  bone  follow  divi- 
,sion  of  the  sciatic  nerve  in  animals ;  in  some  instances  there  was  a 
lengthening,  in  others  a  thickening  and  increased  weight,  and  at  other 
times  marked  flexibility  and  diminution  of  the  specific  weight.  Ghel- 
lini  found  that  in  rabbits  which  were  given  their  freedom  division  of 
the  sciatic  was  followed  by  shortening  of  the  paralysed  leg,  while 
lengthening  took  place  in  those  kept  in  a  cage — probably  on  account 
of  the  diminished  pressure. 

'No  further  explanation  is  required  for  the  fragility  which  is  the 
result  of  disease  of  bone  with  subsequent  loss  of  substance,  such  as 
occurs,  for  example,  in  tubercular  and  syphilitic  diseases,  suppuration, 
or  necrosis  ;  tumours,  such  as  cysts,  sarcoma,  or  carcinoma ;  from  the 
presence  of  echinococcus ;  or  abnormal  softness  of  structure  (rhachitis 
and  osteomalacia).  An  abnormal  weakness  and  fragility  of  the  bones  is 
.also  present  in  scurvy,  a  disease  which  was  at  one  time  very  common. 

Idiopathic  Osteopsathyrosis. — But  in  addition  to  these  various  kinds 
of  fragility  of  bone  due  to  this  or  that  cause,  there  is  also  an  idiopathic 
form,  the  etiology  of  which  is  as  yet  completely  unknown.  In  such 
patients,  who  in  all  other  respects  seem  perfectly  well,  the  slightest 
•exhibition  of  violence,  such  as  a  sudden  movement,  a  slight  thrust, 
or  even  turning  over  in  bed,  suffices  to  produce  a  fracture  of  bones 
which  externally  appear  entirely  normal.  The  malady  is  congenital 
in  a  number  of  cases,  and  sometimes  a  pronounced  hereditary  taint 
runs  through  many  generations.  In  other  cases  the  disease  develops 
in  early  youth  or  later,  and  then  usually  persists  throughout  life.  In 
41 


594  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

this  idiopatliic  form  of  fragility  no  gross  clianges  are  found  in  the 
bones.  The  most  probable  cause  of  this  disturbance  of  the  nutrition 
of  the  bones  is  a  change  in  the  composition  of  their  ground  substance. 
The  observations  of  Blanchard,  in  particular,  show  the  frequency  of 
fractures  in  individuals  with  idiopathic  fragilitas  ossium.  He  had  one 
case  of  a  twelve-and-a-half -year-old  girl  who  had  had,  since  the  second 
month  of  her  existence,  forty-one  fractures  from  the  effects  of  very 
slight  violence ;  she  had  had  fourteen  fractures  of  the  right  and  eleven 
of  the  left  leg.  Arnott  had  a  patient  fourteen  years  old  who  since  the 
third  year  of  life  had  had  thirty-one  fractures,  of  which  seven  were  of 
the  right  thigh  and  nine  of  the  right  leg  below  the  knee.  It  is  rather 
remarkable  that  the  repair  of  fractures  in  idiopathic  osteopsathyrosis 
usually  takes  place  easily  and  quickly. 

Strength  of  the  Epiphyses. — As  long  as  the  diaphysis  and  the  epiph- 
ysis, during  the  period  in  which  the  bones  are  growing,  are  connected 
by  a  cartilaginous  symphysis,  the  resistance  at  this  point  may  be  dimin- 
ished by  various  processes,  especially  those  of  an  inflammatory  nature, 
and  a  spontaneous  separation  of  the  epiphysis  may  thus  be  produced. 
Under  this  heading  come  the  epiphyseal  separations  due  to  syphilitic 
processes,  to  scurvy,  and  to  the  primary  infectious  inflammations  of  the 
medulla  (osteomyelitis). 

The  Various  Kinds  of  Fractures — Incomplete  Fractures,  Depressions, 
Fissures. — We  distinguish  complete  and  incomplete  fractures  according 
to  the  extent  to  which  the  bone  is  divided.    To  the  incomplete  fractures 

belong  the  green-stick  fractures  and 
the  fissures.  A  green-stick  fracture 
occurs  in  the  bending  of  a  bone,  by 
which  the  cortical  substance  on  the 

Fig.  389. — Incomplete  fracture  Cgreen-stick  •  i      •     t       i  i  -i  ,i 

fracture)  of  the  clavicle.  couvex  Side  IS  broken  whiic  on  the 

concave  side  it  is  only  pressed  in 
(Fig.  389).  The  depressions  occurring  on  the  skull,  for  example,  as  a 
result  of  pressure  or  a  blow,  can  be  regarded  as  incomplete  fractures 
(Fig.  398).  The  fissures  (Fig.  390)  are  comparable  to  a  crack  in  a  glass 
or  a  plate,  and  occur  especially  in  the  brittle  bones  of  adults,  less  often 
in  those  of  children,  and  are  frequently  combined  Avith  complete  frac- 
tures which  are  received  at  the  same  time.  They  are  particularly  com- 
mon on  the  skull.  In  gunshot  fractures  the  bones  involved  often  sus- 
tain numerous  fissures.  It  is  of  great  practical  importance  to  note  tliat 
fissures  of  this  description,  especially  when  the  fracture  is  near  a  joint, 
sometimes  run  through  the  articular  extremity  of  the  bone  and  pene- 
trate into  the  neighbouring  joint.  If  after  a  gunshot  fracture,  for 
example,  suppuration  should  take  place  at  the  point  where  the  bone 


101.] 


FRACTURES. 


595 


has  been  broken,  this  suppuration  may  travel  along  the  fissure  into 

the  joint. 

Complete  Fractures. — A  fracture  is  complete  when  the  bone  breaks 

into  two    or  more  pieces  which   are   completely  separated  from  one 

another ;   division  of  the    bone  into  two  fragments  takes  place  most 

commonly.  According  to  the  direction 
of  the  line  of  fracture  with  reference 
to  the  longitudinal  axis  of  the  bone  we 
recognise  transverse,  oblique,  spiral, 
and  longitudinal  fractures.  The  pure 
transverse  fractures  are  generally  pro- 
duced by  direct  violence,  and  are  not 


Fig.  390 — Fi'ssures  m  the  femur. 


Fig.  391. — Fractuie  having  the  shape  of  the 
mouthpiece  of  a  flute  [fracture  en  bee  defliite). 


very  common  if  we  disregard  the  separations  of  the  epiphyses.  The 
most  common  fractures  are  the  oblique,  which  are  almost  always  the 
result  of  indirect  violence,  i.  e.,  forcible  bending.  The  fracture  having 
the  form  of  a  clarinet  mouthpiece,  and  first  described  by  French  writers 
{^fracture  en  hec  de  flute),  is  a  pronounced  oblique  fracture  which  occurs 
especially  in  the  tibia  and  femur,  and  was  produced  by  W,  Koch  by 
rotation  combined  with  a  vertically  directed  blow  (Fig.  391).  The 
spiral  or  torsion  fracture  (Figs.  392,  393)  is  produced,  according  to  the 
experiments  of  Koch  and  Bruns,  exclusively  by  twisting,  the  line  of 
fracture  having  the  shape  of  a  spiral  curve.  The  prognosis  of  a  spiral 
fracture  is  more  unfavourable  than  an  oblique  one,  for  the  reason  that 
the  fractured  surfaces  are  very  extensive  and  the  points  of  one  of  the 
fragments  may  readily  penetrate  the  skin  or  be  driven  into  the  other 
fragment  and  cause  considerable  crushing  of  the  bone  marrow. 

Longitudinal  Fractures. — Longitudinal  fractures,  or  the  division  of 
a  bone  into  two  fragments  with  the  line  of  fracture  running  its  entire 


596 


IXJURIES   AND  SURGICAL   DISEASES  OF  BONE. 


length,  are  very  rare  in  the  long,  hollow  bones,  and  most  longitudinal 
fractures  are  merely  extreme  forms  of  oblique  fractures.      Kronlein 

has  described  a  longi- 
tudinal fracture  of  the 
humerus  and  three 
longitudinal  fractures 
of  the  phalanges  of  the 
fingers,  and  he  could 
find  in  literature  only 
one  longitudinal  frac- 
ture through  the  whole 
length  of  the  tibia, 
M-hicli  was  recorded  by 
Gadiiche.  Longitudi- 
nal fractures  have  been 
noted  somewhat  more 
frequently  in  the  short 
bones  (patella,  verte- 
brfe). 

A  Multiple  Fracture. 
— In  a  multiple  frac- 
ture (fractura  multi- 
plex) the  bone  is  either 
broken  at  two  or  three 
different  points  (double, 
threefold  fracture),  or 
the  bone  is  shattered  at 
one  point  into  many  fragments  (comminuted  fracture).  The  term 
multiple  fracture  also  includes  fractures  sustained  simultaneously  by 
several  bones,  particularly  those  which  are  placed  parallel  to  one  another 
in  the  forearm  and  leg.  The  shape  of  the  multiple  breaks  in  the  same 
bone  varies,  of  course,  very  much,  but  a  few  tyj^ical  forms  are  fre- 
quently observed.  These  typical  forms  include  especially  the  T-and 
Y-shaped  fractures,  occurring  at  the  epiphyseal  extremities  of  the  long 
bones  (Figs.  394,  395).  In  the  T  fracture  (Fig.  39-i).  there  is  a  trans- 
verse and  a  longitudinal  break ;  in  the  Y  fracture  two  oblique  breaks, 
the  production  of  which  has  been  studied  experimentally  by  Gurlt, 
Madelung,  and  Marcuse.  In  fractures  from  bending  and  from  torsion 
a  cuneiform  or  rhombic  piece  is  sometimes  bi'oken  out  of  the  con- 
tinuity of  the  bone  (Bruns).  The  outward  appearance  of  a  comminuted 
or  splintered  fracture  (Fig.  396)  presents  great  variations  in  regard  to 
the   number,  shape,  and  size    of   the   individual  fragments.     In  the 


Fig.  392. — Spiral  fracture 
of  the  tibia  (  W.  Koch). 


Fig.  393.— Spiral  fracture  of 
the  femur  (W.  Koch;. 


§  101.] 


FRACTURES. 


597 


worst  cases  there  will  be  found  at  the  point  of  fracture  a  peculiar  soft 
bag  of  skin  like  a  sac  filled  with  crepitating  fragments  of  bone,  or 
the  bones  and  soft  parts  are  crushed  into  a  bloodj  pulp,  as  is  the  case, 
for  example,  in  "  run-over  "  accidents. 

Condition  of  the  Soft  Parts  in  the  Neighbourhood  of  a  Fracture. — 
The  condition  of  the  soft  parts  in  the  neighbourhood  of  a  fracture  is 
exceedingly  important  for  the  prognosis.  All  fractures  in  which  there 
is  a  wound  of  the  soft  parts  penetrating  to  the  line  of  fracture  are 
called  compound  or  open  fractures,  and  must  be  carefully  distinguished 
from  the  subcutaneous  or  simple  fractures — i.  e.,  those  in  which  the 
outer  covering  of  the  soft  parts  has  not  been  opened.  In  the  days  before 
antisepsis  the  compound  or  open  fractures  very  often  terminated  fatally 
from  pyaemia  and  septicaemia.  The  extent  of  the  wound  of  the  soft 
parts  varies  from  an  insignificant  puncture  to  an  extensive  crushing 
and  laceration  of  the  tissues.  The  wound  is  produced  either  by  the 
same  violence  that  produces  the  fracture,  as  in  gunshot  or  run-over 
injuries,  or  the  skin  is  opened  afterwards  by  injudicious  movement  of 
the  fractured  extremity — in  transpoi'tation  of  the  patient,  for  example 
— -or  as  a  result  of  gangrene,  etc.  The  open,  comminuted  fractures, 
the  compound  fractures  of  joints,  particularly  those  found  in  gunshot 
woimds,  and  extensive  mangling  of  the  bones  and  soft  parts  in  run-over 
accidents,  are  the  most  unfavourable  compound  fractures. 

Separations  of  the  Epiphyses. — In  young  subjects,  as  long  as  the 
diaphysis  and  epiphysis  are  connected  by  a  cartilaginous  symphysis, 


Fig.  394. — T-shaped  fracture 
of  the  lower  end  of  the 
femur,  caused  by  a  fall 
upon  the  knee  (Bruus). 


Fig.  39.5. — Y-shaped  fracture 
of  the  condyles  of  the  hu- 
merus, caused  by  a  fall 
upon  the  elbow  (Bruns). 


Fig.  396. — Comminuted  frac- 
ture of  the  lower  end  of 
the  humerus,  caused  by  a 
fall  upon  the  elbow. 


traumatic  separations  of  the  epiphyses  may  occur,  which,  according  to 
Bruns,  are  most  common  in  the  case  of  the  lower  epiphysis  of  the 
femur,  then  in  the  lower  epiphysis  of  the  radius  and  in  the  upper 
epiphysis  of  the  humerus.     The  sj)ontaneous  separations  of  the  epiph- 


59S 


INJURIES  AND  SURGICAL  DISEASES  OF  BONE, 


yses  in  consequence  of  inflammatory  or  suppurative  processes  must  be 
cai-efully  distinguished  from  the  traumatic  separations.  The  traumatic 
sej)arations  are  mainly  the  result  of  exaggerated  movements  in  joints. 
As  a  result  of  these  exaggerated  movements  in  adults,  dislocations  of 
the  joints  take  place,  but  in  children  fractures  through  the  fragile 
epiphyseal  cartilage  or  in  its  neighbourhood.  This  is  the  reason  why 
traumatic  dislocations  are  so  very  rare  in  young  children.  In  infants, 
separations  of  the  epiphyses,  particularly  inter  partum^  are  brought 
about  by  violent  or  unskilfully  performed  obstetrical  operations  (version, 
extraction).  The  age  limit  within  which  epiphyseal  separations  may 
occur  varies  with  the  different  epiphyses.  The  observations  hitherto 
recorded,  for  example,  show  that  the  twenty-fifth  year  of  life  is  the 
latest  period  at  which  a  traumatic  separation  occurs  in  the  upper 
epiphysis  of  the  humerus. 

Symptomatology  and  Clinical  Course  of  Fractures. — The  symptoms  of 
fractures  are  partly  objective  and  partly  subjective.  The  most  im- 
portant objective  symptoms  are :   1.  Abnormal  mobility  of  the  bone. 

2.  Crepitus — i.  e.,  the  rub- 
bing sound  which  is  heard, 
or,  more  correctly,  felt, 
when  the  fi'actured  sur- 
faces are  rubbed  together. 

3.  Deformity  of  the  Iji'oken 
bone,  or  rather  of  the  part 
of  the  body  to  which  it 
l)elongs,  in  consequence  of 
the  displacement  of  the 
fragments.  Abnormal  mo- 
l)ility  and  crepitus  are  best 
demonstrated  by  seizing 
both     fragments     in     the 

neighbourhood  of  the  line  of  fracture  and  moving  them  in  opposite 
directions.  Kotary  movements  may  also  be  tried  in  cases  of  fractures 
of  the  articular  ends  of  bones.  Abnormal  mobility  and  crepitus  are 
absent  in  impacted  fractures,  in  fractures  with  sharp,  toothed  frag- 
ments which  interlock,  and  in  incomplete  fractures.  Crepitus  will  also 
be  absent  when  the  fractured  surfaces  are  not  in  immediate  contact 
with  one  another.  The  soft  friction  sound  which  is  sometimes  emitted 
by  dried  extravasations  of  blood  or  by  inflammatory  processes — of  the 
tendon  sheaths,  for  example— must  be  carefully  distinguished  from  the 
harder  bony  crepitus.  Deformity  is  caused  by  the  displacement  of  the 
fragments.     We  recognise  the  following  four  principal  kinds  of  dis- 


FiG.  397. — The  ditierent  varieties  of  displacement. 


§  101.]  FRACTURES.  599 

placement,  which  sometimes  occur  separately  and  sometimes  combined 
in  various  ways:  1,  Angular  displacement  (dislocatio  ad  axin,  Fig. 
397,  a) ;  2,  lateral  displacement  (dislocatio  ad  latus,  Fig.  39Y,  h) ; 
3,  displacement  of 

(dislocatio  ad  pe-  a  b 

ripheriam).         The      Fig.  398.— «,  Fracture  of  the  skull  with  depression,  seen  from  the 
1-]     -]  ,     .  ,•  1  outside  (caused  by  a  fall  upon  a  pointed  stone);  6,  the  same 

SO-CalleCl     OVerria-  fracture  seen  from  within  (Bergmann). 

ing  of  the  frag- 
ments— the  pushing  of  one  over  the  other  (Fig,  397,  d) — is  a  combina- 
tion of  the  dislocatio  ad  latus  and  ad  axin,  sometimes  with  the  addition 
of  a  dislocatio  ad  longitudinem.  The  so-called  diastasis  of  the  frag- 
ments (Fig.  397,  e)  and  the  reverse  or  impaction  of  the  fragments  are 
to  be  regarded  as  a  dislocatio  ad  longitudinem.  There  is  a  variety  of 
displacement,  occurring  mainly  in  fractures  of  the  skull,  which  is  called 
depression  of  the  fragments  (Fig.  398,  «,  h). 

The  different  displacements  are  sometimes  primary  and  produced 
by  the  fracturing  force,  and  at  other  times  secondary,  occurring  sooner 
or  later  after  the  injury  as  a  result  of  voluntary  or  involuntary  muscu- 
lar contractions,  of  transportation,  examination,  the  position  the  injured 
member  is  caused  to  assume,  of  defective  dressings,  etc. 

Subjective  Symptoms  of  Fracture — Pain  and  Disturbance  of  Function. 
— The  sulijective  symptoms  of  fracture  are  pain  and  disturbed  function. 
The  pain  and  tenderness  on  pressure  are  most  marked  directly  at  the 
pcrint  of  fracture.  Above  and  below  the  line  of  fracture  the  bone  is 
not  at  all  tender  on  pressure.  This  linear  character  of  the  pain,  so  to 
speak,  is  of  great  diagnostic  importance  in  doubtful  cases. 

The  disturbance  of  function  which  occurs  in  fractures  needs  no  fur- 
ther explanation.  In  consequence  of  the  division  of  the  bone,  an 
extremity,  for  example,  loses  its  bony  support,  and  the  muscles  their 
fixed  points  of  attachment.  The  amount  of  functional  disturbance 
depends  principally  upon  the  amount  of  the  abnormal  mobility,  dis- 
placement, and  deformity,  and  also  upon  the  nature  and  location  of  the 
fracture.  If,  for  instance,  only  one  bone  is  broken  in  a  limb  which 
contains  two,  the  functional  disturbance  may  be  very  slight,  varying 


600  IXJURIES  AND  SURGICAL   DISEASES   OF   BONE. 

with  the  importance  of  the  broken  bone.  Thus  in  fractures  of  the 
fibula  the  patient  will  still  be  able  to  walk,  and  in  fractures  of  the 
ulna  use  of  the  forearm  is  possible,  especially  pronation  and  supination. 
The  disturbance  of  function  is  also  slight  in  the  case  of  impacted  frac- 
tures, and  patients  with  an  impacted  fracture  of  the  neck  of  the  femur 
can  stand  and  walk.  Moreover,  in  impacted  fractures  of  the  articular 
extremities  of  other  bones  the  movements  of  the  joint  involved  are 
often  very  little  or  not  at  all  disturbed. 

Fever  in  Simple  Fractures. — Apart  from  these  local  symptoms  at 
the  point  of  fracture,  we  sometimes  observe  fever  following  the  recep- 
tion of  subcutaneous  fractures.  The  thermometrical  measurements 
made  by  Volkmann,  P.  Bruns,  Grundler,  and  myself,  show  that,  as  a 
rule,  more  or  less  fever  exists,  particularly  during  the  fii-st  few  days 
after  the  injury.  The  height  of  the  fever  varies  between  101.3°  and 
102.2°  F.,  though  in  rare  instances  the  temperature  may  rise  to  104°  F. 
In  twenty-five  out  of  twenty-six  cases  of  subcutaneous  fracture 
Grundler  observed  a  rise  of  temperature  to  99.1°  F.  The  cause  of  this 
febrile  movement  is  ascribed  by  Bergmann,  Wahl,  and  Angerer  to  the 
absorption  of  dead  tissue  elements,  and  especially  of  fibrin  ferment 
and  other  ferments  which  are  formed  in  the  extravasated  blood  near 
the  point  of  fracture,  as  described  in  §  62.  The  fever  is  essentially  a 
ferment  intoxication. 

Suppuration  in  Simple  Fractures. — As  a  rule,  subcutaneous  fractures 
heal  without  suppuration,  and  the  latter  only  occurs  when  micro- 
organisms gain  access  to  the  point  of  fracture  through  some  small  cuta- 
neous wound  or  through  the  blood  ;  the  extravasated  blood  and  the 
injured  (necrotic)  tissues  furnish  a  favourable  nutritive  medium  for 
their  development. 

Course  of  Compound  Fractures. — The  course  of  compound  fractures 
varies  greatly,  according  to  the  size  of  the  wound  in  the  soft  parts,  the 
condition  of  the  fragments,  and  the  treatment.  The  favourable  cases 
are  those  with  a  small  cutaneous  wound,  which,  before  infection  occurs, 
heals  by  immediate  adhesion  of  the  opposed  wound  surfaces,  or  beneath 
a  scab  jper  primaTn  intentionem.  Under  these  conditions  they  run  a 
course  like  that  of  a  subcutaneous  fracture. 

The  worst  cases  of  compound  fractures  are  those  in  which  the  soft 
parts  are  so  extensively  destroyed  that  the  preservation  of  the  liml)  is 
entirely  out  of  the  question.  To  these  may  be  added  the  cases  in 
which  there  is  extensive  splintering  of  the  bones  or  a  perforation  into 
a  joint  or  one  of  the  cavities  of  the  body.  But  as  a  general  thing  it  is 
more  the  extent  of  the  injury  to  the  soft  parts  than  the  severity  of  the 
injury  sustained   by  the  bones  which  determines  the  gravity  of  the 


§  101.]  FRACTURES.  601 

case.  Any  simple  division  of  the  bone  which  is  accomjjanied  by  great 
destruction  of  soft  parts  is  to  be  regarded,  in  point  of  prognosis,  as  a 
more  severe  injury  than  a  splintering  of  bone  which  is  in  itself  con- 
siderable but  is  not  accompanied  by  any  great  amount  of  injury  to  the 
soft  parts. 

The  clinical  course  of  a  comjjound  fracture  is,  moreover,  affected  in 
a  very  marked  degree  by  the  way  in  which  it  is  treated.  The  sooner  a 
compound  fracture  is  placed  under  the  protection  of  antiseptic  treat- 
ment— i.  e.,  the  sooner  the  wounded  soft  parts  and  the  seat  of  the  frac- 
ture are  thoroughly  disinfected,  the  drainage  of  the  wound  attended  to, 
and  an  antiseptic  dressing  a]Dplied — the  sooner  is  a  satisfactory  course 
of  repair  guaranteed. 

If  we  leave  out  of  consideration  those  compound  fractures  which 
heal  aseptically  and  without  any  reaction,  the  local  symptoms,  in  the 
majority  of  cases,  consist  in  a  more  or  less  severe  inflammatory  swell- 
ing in  the  parts  surrounding  the  wound  and  point  of  fracture.  The 
discharge  from  the  wound  is  at  first  thin  and  discoloured  by  blood.  In 
the  aseptic  cases  it  is  limited  in  amount  and  does  not  become  suppura- 
tive. In  the  cases  which  do  not  run  an  aseptic  course  the  discharge  is 
plainly  purulent  or  even  sanious — in  other  words,  it  undergoes  decompo- 
sition in  consequence  of  infection  by  micro-organisms.  The  production 
of  supj)uration  and  putrefaction  is  favoured  by  extensive  destruction  of 
the  soft  parts  at  the  time  of  the  injury.  This  putrefactive  suppuration 
can,  if  the  escape  of  the  discharge  is  prevented,  readily  take  on  a 
spreading  character  in  the  shape  of  a  progressive  gangrenous  cellulitis, 
which  may  endanger  the  preservation  of  the  limb  and  of  life.  If  the 
suppuration  or  putrefaction  runs  a  favourable  course,  the  surface  of 
the  wound  gradually  "  purifies  "  itself — i.  e.,  the  superficial  gangrenous 
portion  of  the  wound  is  slowly  cast  off  by  a  demarcating  suppuration, 
red  granulations  make  their  appearance,  and  the  wound  fills  with  ger- 
minal tissue  which  then  ossifies.  The  suppuration  around  the  ends  of 
the  fragments  which  have  become  necrotic,  or  around  splinters,  is 
sometimes  very  tedious,  and  there  is  always  the  possibility  of  the  pus 
burrowing  or  giving  rise  to  infectious  suppuration  in  the  periosteum 
or  the  bone  marrow,  or  causing  lymphangitis,  phlebitis,  etc.,  and  thus 
death  from  septicaemia  or  pytemia.  By  long  confinement  to  bed,  or 
from  protracted  fever  or  profuse  suppuration,  the  patient  may  become 
so  exhausted  and  such  serious  degenerations  of  the  internal  organs  may 
occur,  that  life  is  imperilled. 

Throughout  the  entire  period  occupied  by  the  process  of  repair,  the 
temperature  of  the  patient  should  be  taken  two  or  three  times  a  day,  and 
at  every  new  rise  of  temperature  the  wound  should  be  carefully  exam- 


602  INJURIES  xVXD  SURGICAL   DISEASES  OF   BOXE. 

ined  to  determine  the  j^resence  of  any  disturbance,  such  as  a  burrowing 
of  pus,  a  deeply  located  spreading  inliammation  and  suppuration,  etc. 

Not  infrequently,  after  a  compound  comminuted  fracture  has  healed, 
fistulse  will  persist  for  a  long  time  ;  they  indicate  the  presence  of  some 
encapsulated,  necrotic  j^iece  of  bone — a  so-called  sequestrum. 

Condition  of  the  Urine  in  Fractures.— As  a  result  of  the  absorption  of 
blood  from  the  point  of  fracture,  the  urine  very  frequently  contains  urobilin, 
a  derivative  of  the  colouring  matter  of  blood,  which,  on  shaking  the  urine 
with  a  solution  of  chloride  of  zinc  and  animouia,  causes  the  urine  to  assume 
a  yellowish-green  fluorescence.  Fat  is  also  very  often  found  in  the  urine  ;  it 
is  derived  as  fluid  fat  from  the  crushed  medullary  portion  of  the  bone  and 
the  fat  in  the  neighbouring  soft  parts,  and,  passing  through  the  circulation, 
is  excreted  by  the  kidneys.  We  shall  learn  further  on  that  it  can  sometimes 
accumulate  to  a  dangerous  degree  in  the  lungs  and  brain.  The  amount  of 
fat  in  the  urine  varies  greatlj*,  depending  upon  the  severity  of  the  injur}-  to 
the  marrow  and  soft  parts ;  in  some  cases  it  is  found  onlj"  in  traces,  while  in 
others  there  may  be  large  quantities  of  it.  Occasionally  it  is  so  abundant 
that  it  is  visible  in  the  form  of  smaller  or  larger  drops  on  the  surface  of 
the  urine.  Most  commonly  the  fat  is  mixed  with  the  urine  in  the  form  of  an 
emulsion,  and  Scriba  maintains  that  this  occurs  in  almost  every  case  of  frac- 
ture. After  the  urine  has  been  allowed  to  stand  for  some  time  a  white  laj-er 
develops  on  its  surface,  which  the  microscope  shows  is  made  up  of  small  and 
minute  fat  drops.  According  to  Scriba,  the  excretion  of  fat  by  the  kidneys 
takes  ])Iace  periodically,  corresponding  to  the  sweej^ing  away  of  the  fat  em- 
boli in  the  lungs.  This  is  the  i^eason  why  the  urine  during  the  repair  of  a 
fracture  changes  so  much,  containing  fat  for  several  days  and  then  being  free 
from  it  for  five  to  six  to  ten  days.  The  excretion  of  fat  begins  on  the  second 
to  the  fourth  day  after  the  injury,  and  usually  ceases  on  the  twentieth  to  the 
twenty-fourth  daj'. 

In  addition  to  fat,  the  urine  of  patients  with  fractures  sometimes  contains 
albumen  and  casts.  The  amount  of  albumen  and  casts  is  greatest  in  the  first 
twenty-four  to  forty-eight  hours,  and  the  condition  lasts  about  four  to  six 
days.  Besides  hyaline  casts  Riedel  found  other  casts  studded  with  numerous 
brown  granules  like  those  which  occur  in  bilious  pneumonia  and  other  dis- 
eases accomjianied  by  degenerative  changes  in  the  blood.  Tlaese  brown  casts 
are  irregular  in  their  occurrence  in  fi-actures  and  are  frequently  entirely  ab- 
sent, while  in  other  instances  they  appear  in  great  numbers.  Riedel  ascribes 
the  origin  of  these  brown  casts  to  the  absorption  of  red  blood-corpuscles  at 
the  point  of  fracture.  Thej-  are  obtained  experimentally  by  producing  frac- 
tures artificially,  by  injecting  blood  into  the  peritoneal  cavity,  and  by  inject- 
ing Kohler's  fibrin  ferment.  Both  Orth  and  myself  have  occasionally  found 
very  large  collections  of  red  corpuscles  and  of  the  colouring  matter  of  blood 
in  the  lymph  glands  and  in  the  internal  organs.  The  hsematogenous  jaun- 
dice which  sometimes  occurs  is  similarly  explained  by  the  presence  of  disin- 
tegrated red  corpuscles  and  blood-colouring  matter  in  the  circulation. 

Repair  of  Fractures. — Fractures  either  heal  j)^f  JyTimam  or  j9^r  se- 
cundam  intentionem^  in  the  same  way  as  described  in  §  61  for  wounds 


101.] 


FRACTURES. 


603 


of  soft  parts.  Simple  fractures,  as  a  rule,  heal  jper  prirnam  inten- 
tio7iem,  while  compound  fractures  heal  j9e;'  secundam  intentionem.  As 
we  remarked  above,  suppuration  takes  place  in  exceptional  cases  of 
subcutaneous  fractures  from  the  entrance  of  micro-organisms  through 
an  abrasion  of  the  skin  or  by  means  of  the  circulation. 

Whether  a  fracture  heals  with  or  ^vithout  suppuration,  the  anatom- 
ical changes  are  essentially  the  same,  and  consist,  briefly  speaking,  in 
the  formation  at  the  point  of  fracture  of  cellular  tissue,  which  is  at  first 
soft,  and  later  is  gradually  changed  into  bone  by  the  ossifying  action  of 
the  periosteum  and  marrow.  The  ossifying  tissue  at  the  point  of  frac- 
ture is  called  the  callus. 

Anatomical  Changes  in  the  Formation  of  the  Callus.— The  anatomical 
changes  which  take  place  in  the  formation  of  the  callus  are  histologically 
an  ossifying  periostitis  and  osteomyelitis. 
The  extravasated  blood  at  the  point  of 
fracture  plays  no  active  part  in  the  forma- 
tion of  the  callus,  and  is  gradually  sup- 
planted by  a  germinal  tissue  rich  in  cells 
and  vessels.  The  outer  or  periosteal  callus 
originates  from  the  inner  layer  of  jjerios- 
teum,  which  contains  osteoblasts,  while 
the  marrow  forms  the  inner  or  medullary 
callus  (Fig.  399).  The  callus  between  the 
broken  ends  of  the  bone  is  called  the  inter- 
mediary callus,  and  is  mainly  jjroduced  by 
growth  of  the  periosteal  germinal  tissue 
between  the  fractured  surfaces ;  the  tissue 
of  the  opened  Haversian  canals  and  the 
marrow  only  shares  to  a  slight  extent  in 
the  formation  of  the  intermediary  callus. 
The  view  which  formerly  prevailed — name- 
ly, that  the  surrounding  soft  paints  were 
capable  of  contributing  to  the  formation 
of  the  outer  callus — is  untenable  in  the 
light  of  our  present  knowledge  of  the  nor- 
mal development  of  bone. 

The  Normal  Formation  of  Bone— The 
Development  of  Bone.— It  is  now  generally 
believed  that  the  normal  development  of 
bone  is  mainly  the  result  of  successive  ap- 
positions of  bone  substance  due  to  the  ac- 
tivity of  the  medullary  tissue,  the  cells  of 
which  change  into  specific  bone-forming 
cells  —  the  so-called  osteoblasts  (Gegen- 
baur.  Fig.  400). 

The  medullary  tissue  may  spring  either  from  the  periosteum  or  from 
cartilage.     The  periosteum  or  perichondrium  (in  the  cartilaginous  bones  of 


K      M 

Fig.  399. — Longitudinal  section  through 
a  fracture  of  the  femur  three  weeks 
old:  P,  periosteum;  X,  bone  ;  J/,  me- 
dulla. Periosteal  callus  and  medul- 
lary callus.  The  intermediary  callus 
consisting  of  periosteal  granulation- 
tissue,  -vrhich  is  ossified  only  in  some 
places  and  is  partly  cartilaginous. 


^£i. 


604  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

the  embryo)  is  made  up  of  two  layers,  an  outer  fibrous  layer  and  an  inner 
layer  of  osteoblastic  cells.  In  this  latter  layer  medullary  spaces  develop,  and 
in  them  the  osteoblasts  from  an  active  formation  of  cells  and  growth  of  ves- 
sels. In  addition  to  the  periosteal  or  perichondria!  bone  formation  we  recog- 
nise an  endochondrial  bone  for- 
mation in  the  cartilage  of  em- 
bryonic bone ;  this  takes  place 
especially  in  the  growth  of  the 
long  bones  at  the  epipliyseal  ,iunc- 
tion.  Medullary  cavities  develop 
here  also,  and  a  portion  of  the 
medullary  cells  change  into  osteo- 
blasts. Opinion  differs  as  regai'ds 
the  importance  of  the  cartilage 
cells  in  the  endochondrial  forma- 
FiG.  400.-?eriosteal  formation  of  bone  from  osteo-  ^j^^^  ^f  ^one,  Virchow  and  others 
blasts,  «;  o,  newly  lorined  bone;  c,  old  bone.  ' 

X  300.  believing  that  the  cartilage  cells 

change  into  medullary  cells  and 
osteoblasts,  while  Gegenbaur  and  Strelzoff  maintain  that  the  cartilage  cells, 
as  such,  perish,  and  take  no  part  in  the  formation  of  bone.  The  latter 
authorities  hold  the  view  that  the  osteoblasts  are  always  derived  from  the 
marrow  or  the  osteoblastic  layer  of  the  periosteum.  The  formation  of  bone 
from  the  medulla  takes  place  in  the  same  way  as  from  the  periosteum  and 
cartilage.  Aseptic  foreign  bodies,  particularly  absorbable  pieces  of  bone  that 
contain  calcium,  favour  bone  regeneration  and  bone  formation  (Barth,  Neu- 
ber,  and  others).  Maas's  view  that  the  colourless  blood-corpuscles  are  ca- 
pable of  forming  the  callus  seems  to  me  untenable. 

The  transformation  of  the  osteoblasts  into  bone  tissue  is  brought  about 
by  a  change  of  the  greater  part  of  the  protoplasmic  material  into  a  tissue 
which  appears  homogeneous,  but  is  really  made  up  of  fine  fibrils,  which, 
after  taking  up  bone  salts,  forms  a  lamellated  ground  substance.  Here  and 
there  cells  persist  as  bone  cells,  which  are  enclosed  by  the  newly  formed 
bone  in  seri'ated  cavities,  having  fine  processes  radiating  from  them.  These 
are  the  so-called  bone-corpuscles.  Meyer  and  the  mathematician  Cullmann 
were  the  first  to  show  that  the  bony  structure  and  trabeculee  are  arranged 
according  to  mechanical  laws. 

Interstitial  Growth  of  Bone.— In  addition  to  this  appositional  growth  of 
bone  from  the  periosteum  and  medulla.  Oilier,  Virchow,  and  others  have 
called  attention  to  the  occurrence  of  an  interstitial  gi'owth — i.  e.,  an  ex- 
pansion of  the  bone  substance  already  formed.  This  was  demonstrated  by 
driving  pegs  and  boring  holes  into  growing  bone. 

Artificially  Increased  Growth  of  Bone.— Under  such  pathological  con- 
ditions as  necrosis,  chronic  inflammatory  processes,  compound  fractures, 
chronic  joint  inflammations,  etc.,  as  a  result  of  irritation  of  the  epiphyses, 
an  increased  growth  of  bone  is  observed,  especially  in  the  long  axis.  The 
longitudinal  growth  can  be  artificially  increased  and  shortening  compen- 
sated for  by  driving  ivory  pegs  into  the  bone,  or  tying  off  the  extremity 
with  an  elastic  tourniquet,  or  by  other  forms  of  irritation  acting  upon  the 
diaphysis  in  the  neighbourhood  of  the  epiphysis,  from  which  the  effects  are 


101.] 


FRACTURES. 


605 


transmitted  to  the  epiphyseal  cartilage  (Oilier,  Langenbeck,  etc.).  In  the 
case  of  a  compound  fracture  which  healed  slowly  with  suppuration,  I  saw 
a  shortening  of  eight  centimetres  in  the  beginning  changed  to  three  centi- 
metres in  the  course  of  about  one  to  one  and  a  half  year  as  a  result  of  an 
abnormal  stimulation  of  the  growth.  Sometimes,  even  in  subcutaneous 
fractures,  the  shortening  which  may  exist  at  first  disappears  after  a  year  or 
two  by  augmented  longitudinal  growth. 

Absorption  of  Bone  Substance. — Simultaneously  with  the  new  forma- 
tion of  bone  there  is  constantly  taking  place,  on  both  the  outer  and  inner 
surface  of  the  bone,  an  absorption  of  the  bone  substance  which  is  brought 
about  by  special  cells  called  osteocl&.sts  (Kolliker).  These  osteoclasts  (Fig.  401) 
usually  have  the  appearance  of  polynucleated  giant  cells,  and,  according  to 
Kolliker,  are  derivatives  of  the  osteoblasts  ;  but  Wegner  maintains  that  they 
are  formed  by  proliferation  of  adventitia  cells,  and  Eecklinghausen,  that 
they  originate  from  white  blood-corpuscles.  According  to  Pommer,  the  cells 
of  the  adventitia  of  the  blood-vessels,  the  endothelial  cells  of  the  perivascular 
lymph  spaces,  and  of  the  Haversian  blood-vessels  themselves — in  short,  the 
protoplasm  of  all  the  cells  lying  near  the  bone  substance — are  capable, 
under  certain  conditions,  of  taking  on  osteoclastic  functions.  Pommer  states 
that  the  subsequent  history  of  the  osteoclasts,  as  well  as  their  derivation, 
varies,  and  that  osteoblasts  or  other  cells  may  be  made  from  them.  He 
ascribes  the  cause  of  the  production  of  the  osteoclasts  to  the  increase  in  the 
local  blood  pressure.  The  action  of  the  osteoclasts  is  entirely  local,  the  bone 
disappearing  in  the  form  of  small  pits  or  lacunae  (Howship's  lacunae,  lacunar 
bone  resorption.  Fig.  401).  The  osteoclasts  probably  form  carbonic  acid,  by 
which  the  lime  salts  are  dissolved,  and  the  rest  of  the  ground  substance  is 
assimilated  by  the  osteoclasts  or  absorbed  by  the  blood  or  lymph  current. 

The  Ossification  of  the  Callus.— The  ossification  of  the  callus  takes  place 
in  precisely  the  same  way  as  in  the  development  of  bone.  The  germinal 
tissue  either  ossifies 
as  such,  or  there  is 
first  a  production  of 
hyaline  or  fibrous 
cartilage.  In  the 
deepest  layers  of  the 
periosteal  germinal 
tissue,  and  hence 
close  to  the  bone,  at 
a  little  distance  from 
the  broken  ends  and 
in  the  neighbour- 
hood of  the  normal 
intact       periosteum, 

there  appear  by  the  third  or  fourth  day  small  collections  of  bone-like, 
"  osteoid "  tissue.  A  network  of  bony  trabecular,  with  enclosed  medullary 
spaces,  gradually  develops.  During  the  second  week  the  formation  of  the 
periosteal  callus  is  so  far  advanced  that  it  consists  of  a  great  number  of 
osteoid  and  osteal  trabeculae— -in  other  words,  the  two  fragments  are  bound 
together  by  a  young  osteophyte  made  of  wide-meshed  bone  tissue.     At  the 


Fig.  401. 


-Lacunar  absorption  of  bone  by  osteoclasts  ( 0),  -which 
lie  in  Howship's  lacunar,     x  260. 


606 


IXJL^KIES  AND  SURGICAL   DISEASES  OF  BONE. 


end  of  the  third  week  (Fig.  39i))  the  periosteal  callus  usually  consists  of  fairly 
firm,  spongy  bone.  Simultaneously  with  the  formation  of  the  periosteal 
callus  the  internal  (myelogenic)  callus  develops  in  the  medulla  of  the  bone 
in  the  same  way.  On  the  inner  surface  of  the  cortex  a  trabecular  system  of 
osteoid  tissue  is  formed,  wliich  gradually  changes  into 
true  bone  by  the  deposition  of  bone  salts.  The  size 
of  the  medullary  callus  varies  greatly,  oftentimes  fill- 
ing the  entire  medullary  cavity,  while  in  other  in- 
stances it  may  only  develop  to  a  slight  extent.  In  the 
medullary  callus  also,  particularly  in  the  neighbour- 
hood of  the  point  of  fracture,  hyaline  and  fibrous  car- 
tilage is  found,  though  not  so  constantly  nor  in  so 
large  amounts  as  in  the  periosteal  callus.  The  so- 
called  intermediary  portion  of  the  callus,  which  lies 
between  the  broken  ends,  develops,  as  we  remarked 
before,  principally  from  the  periosteum. 

Retrogressive  Metamorphosis  of  the  Callus.— At 
the  outset  the  callus  is  made  up  of  spongy  bone  rich 
in  marrow.  This  so-called  provisional  callus  is  then 
transformed  into  the  permanent  bone  cicatrix  hy  be- 
coming more  compact,  decreasing  in  circumference, 
and  becoming  smooth  on  its  surface.  This  involution 
of  the  callus  may  reach  such  completeness  that  the 
bone  cicatrix  is  later  on  scarcely  visible.  If  the  med- 
ullary cavity  was  closed  by  the  medullary  callus  it 
may  again  become  free  by  absorption  of  bone.  Wher- 
ever the  bone  substance  formed  in  the  ossification  of 
the  callus  is  not  functionally  necessary  it  is  absorbed ; 
while,  on  the  other  hand,  apposition  of  bone  substance  takes  place  in  those 
parts  of  the  callus  where  they  are  necessary  for  the  firmness  of  the  bone 
cicatrix.  In  this  way  the  structure  of  the  bone  at  the  point  of  fracture  is 
regenerated  as  completely  as  possible  and  as  the  laws  of  statics  demand.  The 
regeneration  of  the  medulla  is  brought  about  partly  by  the  medullary  cells 
and  partly  by  proliferation  of  the  leucocytes  and  nucleated  red  blood-corpus- 
cles which  increase  rapidly  by  karyomitosis. 

Billroth,  Volkmann,  Oilier,  Bruns,  and  others  have  been  instrumental  in 
elucidating  the  subject  of  the  formation  of  the  callus,  but  the  real  founder 
of  the  experimental  study  of  callus  foi'mation  is  Duhamel  (1740),  who  showed 
by  his  classical  investigations  that  the  callus  is  not  produced  by  any  particu- 
lar fluid  of  the  body  (Galen),  but  by  a  formation  of  bone  from  the  periosteum 
and  marrow. 

The  size  and  circumference  of  a  callus  varies  greatly,  according  to  the 
condition  and  position  of  the  broken  pieces,  the  location  of  the  fracture,  and 
the  size  of  the  bone.  Constitutional  conditions  also  exert  an  influence.  The 
strongest  callus,  as  a  general  thing,  develops  in  fractures  through  the  diaphy- 
sis  of  the  long  bones,  which  heal  with  displacement,  especially  if  the  frac- 
ture has  been  compound.  Considerable  disturbance  of  function  may  be  pro- 
duced by  fractures  like  these  which  heal  in  a  position  of  deformity  with  such 
a  callus  luxurians,  as  it  is  called  (Fig.  402).     The  callus  is  generally  slight  in 


Fig.  402. — Fracture  healed 
with  deformity  (callus 
luxurians). 


101.] 


FRACTUEES. 


6or 


flat  bones  like  the  scapula  or  those  of  the  pelvis.  After  fractures  of  two 
pai-allel  bones  which  lie  next  one  another,  as  is  the  case  in  the  forearm,  it  is 
possible  for  a  synostosis  of  the  two  bones  to  occur.  After  fractures  in  the 
neighbourhood  of  joints  the  callus  sometimes  extends  in  the  form  of  pro- 
cesses into  the  capsule  of  the  joint,  or  bridges  of  callus  develop,  extending 
from  the  articular  end  of  one  bone  to  that  of  the  other,  and  producing  an- 
chylosis of  the  joint.  Occasionally  true  tumours  (callus  tumours)  form  from 
the  callus  at  the  point  of  fracture  ;  these  are  sometimes  benign  osteomata,  or 
enchondromata,  and  sometimes  malignant  periosteal  or  myelogenic  sarcom- 
ata (Haberen).  Lange  observed  the  formation  of  multiple  exostoses  result- 
ing from  ossifying  myositis  which  followed  multiple  fractures  (Fig.  403).  I 
removed  successfully  an  osteochondroma  the  size  of  a  fist  from  the  horizon- 
tal and  descending  ramus  of  the  os  pubis  which  developed  after  a  fracture. 

Effect  of  Divisioii  of  the  Nerves  upon  the  Callus  Formation.— W.  Kusmin, 
experimenting  upon  the  posterior  extremities  of  rabbits,  has  studied  the  effect 
on  the  callus  of  dividing  the  nerves,  and  he  observed  that  after  nerve  divi- 
sion the  callus  is  larger  and  stronger  in  all  its  stages  than  calluses  formed 
without  neurotomy,  and  the  deposit  of  lime  salts  and  ossification  takes  place 
at  an  earlier  period  and  more  extensively  than  is  the  case  under  normal  con- 
ditions. According  to  Kapsamer,  di- 
vision of  the  sciatic  nerve  has  no  in- 
fluence upon  the  callus  formation. 

Behaviour  of  Bone  Splinters.— It 
is  of  special  interest  to  note  what 
happens  to  small  fragments  of  bone. 
Those  which  remain  attached  to  the 
periosteum  or  bone  heal  in  place  the 
most  readily.  But  even  completely 
detached  and  dead  splinters  of  bone 
heal  in  place  by  bony  union  in  the 
case  of  simple  and  of  aseptic  com- 
pound fractures,  but  are  then  gradu- 
ally replaced  by  new-formed  living 
bone  tissue  (see  pages  608  and  609, 
Osteoplasty).  If  bone  fragments  do 
not  become  united  to  the  rest  of  the 
bone,  if  they  die  and  remain  near  the 
point  of  fracture,  consolidation  of 
the  fracture  may,  in  the  case  of  large 
fragments,  be  very  much  delayed,  or 
even  entirely  prevented,  unless  the 
dead  portion  of  bone — the  seques- 
trum, as  it  is  called — is  removed  (see 
§  106,  Necrosis  of  Bone). 

Repair  of  Bone  Defects— Osteo- 
plasty.— The  most  important  method 

of  closing  defects  in  bone  is  that  in  which  living  bone  is  employed  with  a 
broad  nutrient  bridge.  Thus,  in  defects  of  the  skull  a  flap  is  taken  from  the 
immediate  vicinity  of  the  defect  consisting  of  skin  periosteum  and  the  outer 


Fig.  403. — Multiple  exostoses  caused  by  ossify- 
ing myositis  following  multiple  fractures 
(femur  and  pelvis). 


{508  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

table  of  the  skull,  and  this  peduuculated  flap  is  then  turned  into  the  defect, 
where  it  unites  by  bony  union  in  case  the  wound  runs  an  aseptic  course.  It 
is  very  necessary  to  avoid  suppuration.  In  case  of  breaks  in  the  continuity  of 
long  bolaes,  pedunculated  flaps  of  skin,  periosteum,  and  bone  are  also  used,  or 
a  flap  consisting  of  bone  and  periosteum,  with  a  nutrient  bridge  of  periosteum, 
is  formed  from  one  or  both  ends  of  the  bone  and  turned  into  the  defect ; 
or,  finally,  a  flap  of  periosteum  and  bone  which  is  connected  with  the  soft 
parts  may  be  pushed  into  the  defect.  In  suitable  cases  the  defect  may  be 
made  good  by  a  pedunculated  piece  of  bone  from  an  adjoining  bone— e.  g., 
by  splitting  the  bone  in  question  (metatarsal,  metacarpal,  forearm,  leg). 
Finally,  breaks  in  the  continuity  of  the  long  bones  may  be  repaired  by  cut- 
ting off  the  ends  of  the  bone  and  uniting  them  by  nails  or  sutures.  Defects 
in  the  tibia  may  be  repaired  in  this  way  after  resecting  a  corresponding  piece 
of  bone  from  the  fibula.  Bergmann  cured  in  this  way  a  defect  in  the  tibia  of 
about  eleven  centimetres  in  length.  In  one  case  of  defect  in  the  tibia  Hahn 
obtained  a  good  result  by  chiselling  through  the  fibula  and  uniting  its  lower 
end  into  the  medullary  cavity  of  the  upper  portion  of  the  tibia.  The  same 
thing  can  be  done  in  the  case  of  the  forearm. 

In  cases  of  large  defects  in  the  continuity  of  a  bone,  particularly  a  long 
bone,  when  it  is  impossible  to  use  pedunculated  flaps  of  periosteum  and  bone 
or  of  skin,  periosteum,  and  bone  in  the  way  described  above,  and  in  cases 
where  it  is  impracticable  to  unite  the  ends  of  the  bone  by  sutures  or  nails, 
the  defect  may  be  filled  in  with  fresh  sterile  pieces  of  human  bone,  a  half 
to  one  centimetre  in  length  and  a  quarter  to  half  a  centimetre  in  width  or 
thickness,  which  are  in  a  state  of  active  growth,  as  in  the  case  of  the  small 
pieces  of  healthy  bone  obtained  during  a  sequestrotomy  operation.  Spongy 
bone  from  children,  and  any  bone,  in  fact,  obtained  from  bone  operations  on 
children,  is  very  suitable  for  this  purpose.  The  bone  thus  taken  from  the 
living  subject  is  kept  until  used  in  1  to  500  bichloride  at  a  temperature  of  40^ 
C.  (104°  F.).  In  case  it  is  not  possible  to  obtain  fresh  human  bone,  one  can 
make  use  of  small  pieces  of  bone  from  young  growing  animals,  such  as  rab- 
bits, or,  what  is  simpler,  small  pieces  of  dead  bone  material  from  man  or 
animal  which  contains  calcium— e.  g.,  bone  charcoal  (Barth).  The  wound  in 
the  skin  is  sutured  over  the  material  that  is  used  for  filling  purposes,  the 
upper  and  lower  angles  being  left  open.  The  extremity  is  immobilised,  and 
suppuration  must  be  avoided.  Some  authorities  claim  that  small  and  com- 
pletely separated  pieces  of  living  bone  may  heal  in  place  again.  Others, 
however,  have  shown  that  the  living  bone,  like  the  dead  bone  material,  acts 
merely  as  a  temporary  filling  material  ;  it  heals  in  place  only  temporarily, 
acts  as  an  irritant  for  the  new  production  of  bone,  but  is  finally  replaced 
by  new  bone  tissue.  The  calcium  in  the  pieces  of  bone  is  used  for  the 
formation  of  new  bone  tissue.  If  human  osteoblasts  are  implanted  at  the 
same  time,  they  aid  directly  in  the  formation  of  bone.  The  main  point 
is  to  use  bone  material  that  contains  calciimi  and  is  in  an  absorbable  and 
sterile  form  fBarth).  I  healed  a  defect  in  the  tibia,  thirteen  centimetres  in 
length,  resulting  from  complete  necrosis  of  tlie  shaft,  by  the  implantation  of 
numerous  small  pieces  of  bone  taken  from  a  ten-day-old  rabbit  (Fig.  404). 
About  two  thirds  of  the  pieces  of  bone  healed  in  place  without  suppuration, 
and  the  other  third  came  away  in  a  neci'otic  state.     In  a  second  case  I  healed 


§  101.] 


FRACTURES. 


609 


a  defect  in  the  tibia,  nine  centimetres  in  length,  by  the  implantation  of  small 
pieces  of  human  bone  freshly  chiselled.  The  pieces  of  bone,  which  before 
being  used  had  been  placed  for  ten  to  fifteen  minutes  in  1  to  500  bichloride 
of  mercury  at  a  temperature  of  40°  C.  (104°  F.),  all  healed  in  without  suppu- 
ration. In  both  cases  the  skin  wound  was  closed,  except  at  the  upper  and 
lower  angles.  The  use  of  pieces  of  human  bone  and  animal  bone  for  filling 
in  defects  has  been  attempted  by  various  other  surgeons.     The  disk  of  bone 


Tig.  404. — Complete  necrosis  of  the  shaft  of  the  left  tibia  followin?  acute  suppurative  osteomye- 
litis with  extensive  burrowincr  of  pus  in  the  vicinity  of  the  knee.  Kestoration  of  necrotic 
shaft  from  a  to  J  by  transplantation  of  small  pieces  of  bone  from  a  ten-day-old  rabbit 
freshly  killed. 


removed  by  the  trephine  has  sometimes  been  made  to  heal  in  place  again. 
According  to  Barth,  it  is  probably  replaced  gradually  by  newly  formed  bone, 
while  Wolff  and  others  claim  that  the  transplanted  bone  remains  as  such. 

Finally,  different  kinds  of  sterile  dead  substances  have  been  used  as  a 
filling  material  for  bone  defects  or  cavities.  Dead  bone,  either  decalcified  or 
not  decalcified,  has  been  used.  Grekoff  used  with  success  bone  charcoal. 
Neuber  employed  iodoform  starch.  The  calcified  material  is  only  fitted  for 
hone  cavities  ;  the  repair  of  a  large  defect  in  the  continuity  of  a  long  bone 
42 


610  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

is  hardly  possible  with  uncalcified  material.  Bone  defects  in  the  skull  have 
been  closed  by  a  celluloid  plate.  Gluck  attempted  to  heal  large  pieces  of 
ivory  into  defects  in  long  bones,  and  even  to  make  a  sort  of  joint  in  place  of 
a  real  joint.  These  attempts  of  Gluck  have  proved  a  failure.  If  a  large 
dead  piece  of  bone,  such  as  ivory,  is  used  for  movements  or  for  support,  it 
does  not  heal  in  place  permanently,  and  painful  inflammatory  (carious)  pro- 
cesses take  place  in  the  adjacent  living  bone,  so  that  the  foreign  body  has  to 
be  removed,  as  Bergmaun  had  to  do  in  a  case  operated  on  by  Gluck.  In 
rare  cases,  however,  large  foi'eign  bodies  seem  to  have  healed  into  defects  in 
the  long  bones  for  a  certain  time  at  least.  Giordano,  for  example,  seems  to 
have  healed  a  piece  of  iron  twenty-three  centimetres  long  and  ten  to  twelve 
millimetres  thick  into  a  defect  in  the  tibia ;  it  had  a  disk  of  ivory  at  its  upper 
and  lower  end.  Peau  restored  the  upper  half  of  the  humerus  by  introducing 
an  artificial  appliance  made  of  rubber  and  platiuiridium.  Unfortunately, 
subsequent  reports  on  these  cases  have  not  been  given,  which  are  absolutely 
necessary. 

The  temporary  introduction  of  pieces  of  ivory  into  the  medullary  cavity 
of  long  bones  might  come  into  consideration  in  the  case  of  defects  in  the 
extremities  for  the  purpose  of  stimulating  the  growth  of  bone.  Bircher  has 
used  this  method  for  securing  the  ends  of  the  bone  in  compound  fractures 
and  pseudarthrosis.  In  the  majority  of  cases  the  piece  of  ivory  which  had 
been  implanted  was  removed  after  the  bones  had  united. 

As  regards  the  filling  in  of  bone  cavities  with  hardening  material,  such  as 
plaster  of  Paris,  copper  amalgam,  dental  gutta  percha,  and  Eichter's  cement, 
it  is  at  the  present  time  impossible  to  give  a  definite  opinion  of  its  worth,  but 
the  method  deserves  further  trial.  It  is  not  as  yet  suitable  for  defects  in  the 
continuity  of  bones,  but  in  the  case  of  bone  cavities  good  results  have  occa- 
sionally been  obtained.  The  chief  difficulty  consists  in  rendering  a  bone 
cavity  perfectly  germ  free. 

Repair  of  Fractures  of  Cartilage. — The  process  of  repair  in  fractures  of 
cartilage,  such  as  the  ossifying  costal  cartilages  or  laryngeal  cartilages  which 
are  covered  with  perichondrium,  is  mainly  cari-ied  on  by  the  perichondrium, 
and  a  fibrous  cartilage  is  formed,  which  then  gradually  ossifies.  Regressive 
changes  usually  take  place  at  the  broken  ends,  and  the  cartilage  undergoes 
fatty  degeneration,  but  at  a  distance  a  little  farther  removed  from  the  broken 
ends  of  the  cartilage  there  occurs  a  vigorous  proliferation  of  cartilage  cells 
and  a  formation  of  new  cartilage  tissue  (Tizzoni  and  others).  In  cases  of 
intei'ruption  of  continuity  and  loss  of  substance  in  the  cartilage  of  joints 
which  is  not  provided  with  perichondrium,  a  fibrous  connective-tissue  cica- 
trix ordinarily  develops,  which  Tizzoni  states  is  capable  in  time  of  changing 
into  hyaline  cartilage  tissue.  Portions  of  cartilage  which  have  been  com- 
pletely broken  off  do  not  regain  their  attachments,  and  either  become  free 
bodies  in  the  joint  or  are  encapsulated  by  new  connective  tissue  formed  from 
the  inner  surface  of  the  capsule. 

The  Time  required  for  Fractures  to  Heal. — The  time  which  is  re- 
quired for  the  callus  formation  to  reach  completiou  and  render  the 
affected  bone  again  capable  of  performing  its  function,  depends  upon 
the  size  of  the  bone  which  is  involved,  the  nature  of  the  fracture,  and 


§  101.]  FRACTURES.  611 

not  infrequently  also  upon  constitutional  conditions.  A  simple  subcu- 
taneous fracture,  as  a  general  thing,  heals  more  rapidly  than  a  com- 
minuted or  a  compound  fracture  with  considerable  injury  to  soft 
parts.  In  childhood,  union  takes  place  more  rapidly  than  in  adult 
life.  The  healing  of  a  fracture  may  be  prolonged  by  constitutional 
anomalies,  such  as  the  occurrence  at  the  same  time  of  severe  acute 
constitutional  infectious  diseases,  or  by  syphilis,  scurvy,  diabetes  mel- 
litus,  and  not  infrequently  by  pregnancy.  Gurit  has  given  the  follow- 
ing periods  as  those  required  for  the  healing  of  simple  subcutaneous 
fractures  :  A  broken  phalanx  needs  about  two  weeks,  the  metacarpus, 
metatarsus,  and  ribs  three,  the  clavicle  four,  the  forearm  five,  the 
humerus  and  fibula  six,  the  neck  of  the  humerus  and  the  tibia  seven, 
both  bones  of  the  leg  eight,  the  femur  ten,  and  the  neck  of  the  femur 
twelve  weeks  before  consolidation  is  complete.  The  modern  treat- 
ment of  fractures  has  shortened  the  time  of  healing  very  materially. 
This  has  been  brought  about  by  the  use  of  ambulatory  splints,  early 
massage  with  movements  of  the  joints,  and  the  not  too  prolonged  use 
of  immobilising  splints. 

Condition  of  the  Soft  Parts  and  Joints  after  Healing  of  a  Fracture. — 
After  consolidation  of  a  fracture  the  full  usefulness  of  the  joints  is  not 
immediately  restored,  and  the  muscles  very  frequently  have  become 
atrophic  as  a  result  of  their  long  inactivity.  This  muscular  atrophy 
is  probably  in  part  of  spinal  origin,  i.  e.,  it  is  caused  reflexly  by  irrita- 
tion at  the  point  of  injury.  Kiliani  believes  that  it  is  due  mainly  to 
the  toxic  action  of  the  absorbed  extravasation  of  blood  upon  the  cen- 
tripetal nerve  endings.  From  long- continued  immobilisation  or  too 
tight  dressings  this  atrophy  of  the  muscles,  particularly  in  an?emic 
individuals,  may  give  rise  to  the  ischsemic  paralyses  and  contractui-es 
mentioned  on  page  569.  Sometimes  the  functions  of  the  muscles  are 
disturbed  by  cicatricial  shrinkage  as  a  direct  result  of  the  injury,  or 
by  their  insertion  having  been  torn  away,  or  by  paralysis  in  conse- 
quence of  a  complicating  injury  to  the  nerves,  or  from  compression 
of  the  nerves,  for  instance,  by  the  callus.  The  skin  very  often  exhibits 
slight  disturbances  of  nutrition  ;  it  is  dry  and  rough,  and  the  epidermis 
comes  off  in  scales.  Yery  frequently  there  are  varying  degrees  of 
oedema  of  the  skin  and  subcutaneous  soft  parts.  The  rest  which  the 
healing  of  a  fracture  enjoins  also  has  a  deleterious  effect  upon  the  con- 
dition of  the  joints  (Menzel,  Eeyher).  In  consequence  of  the  shrink- 
age of  the  capsule  of  joints  immobilised  by  the  fracture  dressing,  the 
joints  are  more  or  less  stiff  after  the  splint  is  removed,  and  sometimes 
inflammatory  effusions  occur.  Ordinarily,  with  the  increasing  use  of 
the  joint  and  under  proper  treatment  (by  massage  and  passive  motion) 


612 


INJURIES  AND  SURGICAL  DISEASES  OF   BONE. 


these  disturbances  very  soon  disappear.  In  other  eases  joint  inflam- 
mations have  their  foundation  in  a  direct  injury  of  the  joint,  and 
under  these  circumstances  it  is  possible  for  permanent  joint  disturb- 
ances, inflammation  giving  rise  to  deformity,  anchylosis,  etc.,  to  occur 
(see  Diseases  of  JointsV 

Course  of  the  Epiphyseal  Separations. — The  separations  of  the  epiph- 
yses run  essentially  the  same  course  as  fractures  of  the  bone.  We 
still  lack  precise  anatomical  knowledge  upon  the  phenomena  of  their 

healing.  Great  intei'est  attaches 
to  the  question  of  how  much  dis- 
turbance after  epiphyseal  separa- 
tions has  been  observed  in  the 
growth  of  the  affected  bone  on 
account  of  ossification  of  the  epi- 
physeal cartilage.  Unfortunately, 
only  a  few  observations  have  been 
recorded  on  this  subject.  Bruns's 
statistics  show  that  a  consequent 
arrest  of  development  only  occurs 
in  rare  and  exceptional  instances 
to  any  marked  degree.  Yogt  has 
recorded  observations  of  this  kind. 
In  Fig.  405  is  represented  a  short- 
ening of  the  humerus  amounting 
to  twelve  and  one  half  centimetres 
in  a  thirty -year-old  woman  which 
was  probably  the  result  of  a  trau- 
matic separation  of  the  epiphysis  sustained  in  childhood,  with  subse- 
quent anchylosis  of  the  shoulder  joint.  Shortening  develops  especially 
when  the  diaphysis  and  epiphysis  are  driven  into  one  another  and  heal 
together  in  this  position,  or  when,  in  consequence  of  simultaneous  injury 
to  the  adjacent  layer  of  epiphyseal  bone,  a  growth  of  bone  makes  its 
way  through  the  epiphyseal  cartilage  into  the  diaphysis  and  unites  epiph- 
ysis and  shaft  so  that  the  further  growth  is  arrested  (Nove- Josserand). 
Disturbances  during  the  Healing  of  Fractures. — The  most  important 
disturbances  which  may  arise  while  a  fracture  is  healing  are  briefly  as 
follows : 

1.  Shock     See  §  63. 

2.  Delirium  Tremens.     See  §  64. 

3.  Infectioua  Diseases  of  Wounds.  See  §§  66-75. — These  are  par- 
ticularly liable  to  occur  in  the  case  of  compound  fractures  which  have 
not  been  treated  antiseptically. 


FfG.  405. — Impeded  growth  of  the  riglit  hu- 
merus, probably  resulting  from  a  traumatic 
separation  of  the  epiphysis  (Bryant). 


§  101.]  FRACTURES.  ,  613 

4.  Gangrene. — See  §  100. — This  may  be  caused  by  severe  injury  of 
tbe  soft  parts,  by  injury  to  the  larger  vessels,  by  pressure  of  the  frag- 
ments upon  the  main  artery,  by  improper  treatment,  such  as  too  tight 
dressings,  etc. 

5.  Necrosis  of  the  Ends  of  the  Fragments. — This  is  especially  apt 
to  occur  in  compound  fractures  when  the  broken  ends  lie  in  the  wound 
stripped  of  their  periosteum,  or  when  they  are  badly  crushed  or 
splintered  into  several  fragments,  or  when  the  periosteum  and  medulla 
are  to  a  great  extent  destroyed  by  suppuration  and  sloughing.  The 
dead  bone — or  sequestrum,  as  it  is  called — is  then  separated  from  the 
living  bone  by  a  demarcating  suppuration  (see  §  106,  Necrosis  of 
Bone). 

6.  Fat  Emboli. — Probably  in  every  fracture,  as  a  result  of  the 
laceration  of  the  bone  marrow  and  subcutaneous  adipose  tissue,  fluid 
fat  gains  access  to  the  blood  and  lymph  vessels  which  are  opened  at 
the  point  of  fracture.  Wherever  the  lumen  of  the  vessels  is  too  small 
for  the  passage  of  the  fat  drops  circulating  in  the  blood  at  this  point, 
these  drops  lodge  and  occlude  the  vessel.  Fat  emboli  of  this  kind 
following  fractures  are  observed  particularly  in  the  pulmonary  capilla- 
ries, and  they  also  frequently  occur  in  the  smallest  vessels  of  the  brain, 
kidneys,  liver,  intestinal  villi,  etc.  As  long  as  the  fat  emboli  are  scat- 
tered and  not  extensive  their  occurrence  is  entirely  unimportant ;  the 
fat  produces  no  symptoms  worth  mentioning  of  either  a  local  or  consti- 
tutional nature,  beyond  causing  a  temporary  occlusion  of  the  lumen  of 
the  vessel  in  question.  But  sometimes  the  fat  emboli  in  the  lungs  or 
brain  are  so  numerous  and  so  extensive  as  to  cause  death,  not  only  in 
those  weakened  by  age,  but  now  and  then  in  those  who  are  in  the 
prime  of  hfe.  Death  is  due  to  a  pronounced  accumulation  of  fat  in 
the  capillaries  of  either  the  lungs  or  the  brain.  Scriba  has  performed 
experiments  to  determine  the  manner  in  which  fat  emboli  act,  and  he 
maintains  that  death  is  mainly  the  result  of  their  lodgment  in  the 
brain.  As  a  rule,  death  occurs  about  three  to  four  days  after  the  frac- 
ture, and  in  such  cases  there  is  a  continual  accumulation  of  fat,  during 
several  days,  in  the  capillaries  of  the  lungs  and  brain,  which  finally 
causes  a  more  or  less  sudden  functional  incapacity  of  these  organs.  It 
is  comparatively  seldom  that  death  is  the  result  of  fat  emboli  alone ; 
there  are  generally  other  complications. 

T.  Embolism  of  the  Pulmonary  Artery  following  Thrombosis  of 
the  Larger  Veins  at  the  Region  of  Fracture.— Th\Q  serious  complication 
may  occur  particularly  after  thrombosis  of  the  deep  veins  in  fractures 
of  the  lower  extremity.  The  thrombus  in  the  vein  may  break  loose 
either  while  the  patient  is  lying  quietly  in  bed,  or  because  of  some 


GU 


INJURIES  AND  SURGICAL  DISEASES  OP   BONE. 


movement  of  the  body,  from  massage,  or  from  a  change  of  the  dress- 
iuo-,  and  death  may  follow  within  a  few  seconds  from  embolism  of  the 
pulmonary  artery.  Konig  observed  death  from  embolism  of  the  pul- 
monary artery  on  the  eighteenth  day  after  a  subcutaneous  fractm-e  of 
the  leg  in  a  strong  man  thirty  years  of  age.  When  the  patient  was 
laid  upon  the  operating  table  preparatory  to  changing  the  dressings, 
he  was  suddenly  seized  with  cramps  and  opisthotonus,  the  pupils 
became  dilated,  and  he  died  in  a  few  moments.  The  autopsy  revealed 
a  large  clot  lodged  in  the  jjulmonary  artery,  and  it  was  only  with  diffi- 
culty that  the  point  was  found  in  the  anterior  tibial  vein  where  the 
thrombus  had  originated. 

8.  Hmnorrhage. — In  compound  and  subcutaneous  fractures  haemor- 
rhage may  occur  as  a  result  of  the  violence  which  has  been  brought 
to  bear  upon  the  part,  or  it  may  be  produced  by  pointed  fragments, 
splinters  of  bone,  etc.  (see  §§  87-89). 

9.  Constitutional  anomalies  play  an  important  part  in  respect  to 
the  prognosis  in  the  case  of  any  fracture.  A  fracture  sustained  by  a 
very  old  person  and  entailing  a  long  confinement  in  bed  is  a  serious 
accident,  for  the  reason  that  life  may  readily  become  endangered  by 
hypostatic  pneumonia. 

10.  Delay  in  the  formation  of  the  callus  is  particularly  apt  to  occur 
when  constitutional  anomalies  exist,  or  in  acute  and  chronic  infectious 
diseases  (typhoid  fever,  syphilis,  scurvy),  in  diabetes  mellitus,  in  diseases 

of  the  peripheral  nerves 
and  central  nervous  system, 
such  as  progressive  paraly- 
sis, or  during  pregnancy,  etc. 
11.  Pseudai'throsis. — If 
bony  union  does  not  take 
place  between  the  frag- 
ments, the  resulting  condi- 
tion is  called  a  pseudarthro- 
sis — i.  e.,  a  false  joint  (see 
Fig.  406).  In  a  case  of 
pseudarthrosis,  the  frag- 
ments are  either  entirely 
free  from  connection  with 
one  another,  or  they  are  joined  together  by  a  connective-tissue  or  car- 
tilaginous intervening  substance  of  varying  strength.  In  rare  instances 
a  kind  of  true  joint  is  observed  at  the  point  of  fracture — i.  e.,  the  ends 
of  the  fragments  are  covered  with  a  layer  of  hyaline  cartilage,  and  a 
shallow  cavity  is  hollowed  out  of  one  fragment,  while  the  other  is 


Fig.  406.- 


-Pseudarthrosis  of  the  humerus  twelve  years 
old  in  a  lifty-three-year-old  man. 


§101.]  FKACTURES.  Q^^ 

rounded  to  fit  it ;  the  periosteum  and  neighbouring  connective  tissue 
surrounds  and  encloses  the  broken  pieces  in  the  form  of  a  capsule,  and 
in  some  cases  there  will  be  found  in  the  joint-like  cavity  a  fluid  which 
resembles  synovia.  In  pseudarthroses  such  as  this,  even  synovial 
villi  and  loose  bodies  have  been  found,  the  latter  sometimes  in  great 
numbers. 

Occurrence  of  Pseudarthrosis. — In  general,  pseudarthrosis  is  not  of 
common  occurrence.  Karmilow  states  that  a  pseudarthrosis  takes  place 
once  in  about  three  hundred  or  four  hundred  fractures.  The  pseudar- 
throses following  fracture  of  the  neck  of  the  femur  and  fracture  of  the 
patella  are  the  most  frequent.  Bruns's  statistics  seem  to  show  that 
childhood  and  old  age  predispose  less  to  pseudarthrosis  than  middle 
hfe.  In  fact,  pseudarthroses  are  very  rare  in  children,  particularly  in 
the  bones  of  the  forearm,  but  they  are  more  common  in  the  humerus 
and  tibia. 

Causes  of  Pseudarthrosis. — The  causes  of  pseudarthrosis  are  usually 
local  in  their  nature,  being  principally  those  which  prevent  exact  coap- 
tation of  the  wounded  bone  surfaces,  A  pseudarthrosis  may  result,  for 
example,  from  a  diastasis  of  the  fragments,  such  as  often  occurs  after 
transverse  fracture  of  the  patella  or  after  loss  of  a  large  portion  of  a 
bone,  owing  to  its  becoming  extensively  crushed ;  or  the  affection  m&y 
result  from  displacement  of  the  fragments,  or  from  interposition  of 
muscles,  tendons,  fascia,  foreign  bodies  (bullets),  pieces  of  dead  bone, 
«tc.,  between  the  fractured  surfaces.  In  other  cases — for  instance, 
after  intracapsular  fractures  of  the  neck  of  the  femur,  or  intracapsular 
fractures  of  the  neck  of  the  humerus — the  pseudarthrosis  is  caused  by 
the  insufficient  nourishment  of  one  of  the  fragments.  Pseudarthrosis 
may  also  originate  in  consequence  of  insufficient  coaptation  of  the  frac- 
tured surfaces  due  to  defective  dressings,  particularly  if  the  fracture  is 
•oblique  ;  under  these  conditions  the  fragments  are  permitted  to  move 
and  become  separated.  An  influence  is  sometimes  exerted  in  this 
direction  by  a  paralysis  which  may  exist  at  the  time  of  the  fracture,  or 
by  too  little  inflammatory  reaction  in  consequence,  for  example,  of  the 
wound  healing  aseptically  in  the  case  of  compound  fractures.  Consti- 
tutional disturbances,  especially  the  general  weak  condition  which  fol- 
lows severe  febrile  diseases,  loss  of  blood,  prolonged  lactation,  preg- 
nancy, etc.,  have  in  rare  instances  given  rise  to  pseudarthroses.  Under 
these  circumstances  it  has  also  happened  that  an  already  ossified  callus 
has  softened  and  been  completely  absorbed.  Whether  injuries  and 
diseases  of  the  central  nervous  system  and  the  peripheral  nerves  really 
predispose  to  pseudarthrosis,  as  has  been  maintained,  seems  to  me 
doubtful. 


016  INJURIES  AND  SURGICAL   DISEASES   OF   BONE. 

Tlie  degree  of  functional  disturbance  resulting  from  a  pseudarthro- 
sis  depends  mainly  upon  the  location  of  the  latter,  the  function  of  the 
bone  which  is  involved,  and  especially  upon  the  amount  of  motion  pos- 
sessed by  the  false  joint.  In  a  pronounced  pseudarthrosis  of  a  long 
bone,  like  the  femur  or  humerus,  the  affected  portion  of  the  limb  or 
the  entire  extremity  is  quite  useless,  unless  some  supporting  apparatua 
is  worn. 

Diagnosis  of  Fractures. — The  diagnosis  of  fractures  is  made  from  the 
above-described  symptouis.  In  order  to  make  out  the  latter,  a  systematic  and. 
careful  examination  of  the  injury  should  be  undertaken.  This  examination 
consists  :  1.  In  a  thorough  inspection  of  the  injured  portion  of  the  body, 
noting,  for  example,  changes  in  its  shape  and  disturbances  of  function.  2. 
In  palpation  of  the  place  where  the  fracture  is  presumed  to  be,  cojnbined. 
with  passive  motion.  3.  In  an  exact  measurement  of  the  length  of  the  in- 
jured bone,  or,  rather,  the  extremity,  to  determine  the  existence  and  amount 
of  shortening.  Simple  inspection  will  often  be  sufficient  for  the  immediate 
recognition  of  a  fracture.  Entirely  apart  from  the  crepitus  and  abnormal 
mobility,  the  characteristic  linear  pain  obtained  by  palpation  of  the  line  of 
fracture  will  frequently  betray  the  existence  of  a  fracture.  In  order  to  pal- 
pate the  line  of  fracture  more  readily,  the  extravasation  at  the  point  of  frac- 
ture should,  when  pi'acticable,  be  removed,  or  at  least  diminished  in  amount,, 
by  gentle  massage.  The  corresponding  sound  portion  of  the  body  should 
always  be  compared  with  the  injured  part,  with  a  view  to  determining  how 
far  the  normal  position  of  the  constituent  i^arts  has  been  altered  by  the  in- 
jury. Not  infrequently  we  have  to  make  the  examination  during  narcosis  tO' 
find  out  the  exact  nature  of  the  fracture,  especially  when  it  is  compound.  In 
all  cases  where  the  diagnosis  of  fracture  is  doubtful  the  injury  should  alwaj^s 
be  treated,  for  the  first,  at  least,  according  to  the  rules  which  govern  the  treat- 
ment of  fractiires. 

Percussion  and  Auscultation  of  Bones.— Lucke  and  Hueter  have  recom- 
mended percussion  and  auscultation  of  the  bone  as  an  aid  in  the  diagnosis  of 
fractures,  particularly  when  it  is  desired  to  determine  the  presence  of  fissures 
in  the  skull,  which  can  be  recognised  by  the  pain  the  patient  feels  during  the 
percussion.  If  soft  parts  are  interpo.sed  between  the  ends  of  the  fragments,. 
Hueter  states  that  auscultation  (osteophony)  will  show  a  diminution  or  com- 
plete cessation  of  the  conduction  of  sound. 

As  regards  the  use  of  the  X-rays  in  the  diagnosis  of  injuries  and  diseases 
of  bone,  see  §  124. 

The  Prognosis  of  Fractures.— The  prognosis  of  subcutaneous  fractures 
without  much  injury  of  the  surrounding  soft  parts  is,  in  general,  favourable. 
Transverse  fractures  heal  more  rapidly  and  are  less  apt  to  cause  lasting  de- 
formity than  oblique  fractures.  The  location  of  the  fracture  is  an  exceedingly 
important  matter  as  regards  the  prognosis.  The  latter  is  more  favourable  in 
fractures  of  the  extremities  than  in  those  of  the  bones  of  the  skull,  trunk, 
and  pelvis,  in  which  the  concomitant  injuries  of  neighbouring  organs  of 
vital  importance,  such  as  the  brain,  spinal  cord,  lungs,  heart,  bladder,  etc., 
may  i-eadily  give  rise  to  very  serious  disturbances  or  death.     In  other  cases 


§  101.]  FRACTURES.  617 

injury  to  a  neighbouring  large  vessel  may  cause  fatal  haemorrhage,  or,  when 
the  middle  meningeal  artery  is  wounded,  cerebral  compression,  with  possibly 
fatal  results. 

Fractures  of  the  lower  extremities  in  old  people,  necessitating  their  con- 
fiaement  to  bed  for  weeks,  are  always  to  be  looked  upon  as  severe  injuries. 
As  a  result  of  the  long-continued  dorsal  decubitus,  general  disturbances  of 
nutrition,  bronchitis,  and  hypostatic  processes  in  the  lungs  readily  develop, 
which  very  often  terminate  fatally.  This  fact  is  of  therapeutic  importance, 
as  it  teaches  us  in  proper  cases  to  permit  patients  with  fracture  of  the  neck  of 
the  femur,  for  example,  to  get  about  in  ambulatory  splints  as  soon  as  possible. 

The  prognosis  of  fractures  involving  the  articular  ends  of  bones  of  the 
extremities  is  very  frequently  unfavourable,  particularly  as  regards  restora- 
tion of  the  function  of  the  joint. 

The  character  of  the  fracture  exerts  a  very  important  influence  upon  the 
prognosis  as  regards  the  preservation  of  the  patient's  life  and  the  saving  of 
the  injured  limb,  as  well  as  its  complete  restitutio  ad  integrum.  Compound 
fractures,  in  particular,  are  always  to  be  looked  upon  as  severe  injuries,  and 
ones  which  threaten  both  the  limb  and  life  itself,  but  thanks  to  Lister's  anti- 
septic method  of  treating  wounds,  we  are  no  longer  powerless  to  combat 
infectious- wound  diseases.  In  the  pre-antiseptic  times  the  mortality  of  com- 
pound fractures  amounted  to  thirty-five  to  forty  per  cent.,  and  in  especially 
infected  hospitals  even  to  sixty  to  seventy  per  cent,  and  more.  Three  quar- 
ters of  the  fatal  cases  were  due  to  septicagmia  and  pyaemia.  At  present  the 
mortality  of  compound  fractures,  when  timely  and  proper  antiseptic  treat- 
ment is  bestowed  upon  the  wound,  is  extremely  small,  for  the  reason  that  we 
have  learned  to  prevent  infectious- wound  diseases.  From  this  it  is  plain  that 
the  prognosis  of  a  compound  fracture  is,  in  general,  more  favourable  the  ear- 
lier it  is  placed  under  the  protection  of  antiseptic  treatment. 

Frequently  it  may  be  impossible  to  preserve  the  broken  limb,  so  that 
either  immediately  after  the  injury,  or  later,  amputation  of  the  extremity 
must  be  undertaken. 

The  extent  to  which  the  prognosis  of  any  fracture,  subcutaneous  as  well 
as  compound,  may  be  affected  by  various  accidental  circumstances,  has  been 
discussed  on  pages  612-614. 

Treatment  of  Fractures. — The  first  aid  to  the  person  who  has  just 
sustained  a  fracture  often  falls  to  the  share  of  the  laitj  who  happen  to 
be  present  at  the  accident.  Unfortunately,  their  assistance  frequently 
does  more  harm  than  good.  In  fractures  of  the  upper  extremity  the 
patient  usually  instinctively  places  the  broken  limb  in  a  proper  position. 
But  the  conditions  are  entirely  different  in  all  fractures  of  the  pelvis, 
vertebrae,  and  lower  extremity,  in  consequence  of  which  the  injured 
person  is  unable  to  walk.  Under  these  conditions  the  patient  must  be 
lifted  cautiously  after  securely  supporting  the  point  of  fracture.  If  an 
individual  who  has  received  an  injury  of  this  kind  has  to  be  transported 
to  his  home  or  to  a  hospital,  the  fractured  part  should  be  placed  in  the 
most  secure  position  possible,  a  suitable  temporary  dressing  applied  to 


<518  IXJURIES  AND  SURGICAL   DISEASES  OF  BONE. 

prevent  unnecessary  pain  and  displacement  of  tlie  ends  of  the  frag- 
ments, as  well  as  serious  injuries,  such  as  perforation  of  the  skin  and 
severe  wounds  of  the  soft  parts,  particularly  of  the  vessels,  with  dan- 
gerous haemorrhage,  etc.  Great  care  should  be  used  in  removing  the 
patient's  clothes,  portions  of  the  latter — his  boots,  etc. — when  necessary, 
being  slit  up  with  a  knife  or  scissors.  The  technique  of  applying  an 
impromptu  dressing,  the  various  splints,  the  arrangement  of  the  bed, 
the  position  of  the  patient,  etc.,  are  described  in  §§  52-55. 

The  treatment  of  the  fracture  itself  consists,  in  the  case  of  a  simple 
fracture,  in  correcting  the  deformity  as  soon  as  possible — i.  e.,  in  repo- 
sition or  reduction  of  the  fragments,  and  in  retention  or  fixation  of  the 
broken  pieces  after  they  have  been  placed  in  apposition  by  a  suitable 
retentive  dressing  until  bony  union  is  complete. 

Reduction  of  the  Fragments. — Reduction  or  return  of  the  disjjlaced 
fragments  into  their  normal  position  is  usually  brought  about  by  exten- 
sion (traction)  and  counter-extension  in  the  longitudinal  axis  of  the 
broken  bone.  The  extension  and  counter-extension  of  the  broken  limb 
are  usually  cautiously  performed  by  two  assistants,  while  the  surgeon 
grasps  the  point  of  fracture  and  brings  the  fragments  into  their  nor- 
mal position  (coaptation).  Manual  reposition  or  reduction  will  almost 
always  be  sufficient.  If  great  force  has  to  be  used,  or  if  the  pain  is 
intense,  an  anaesthetic  may  have  to  be  employed.  Extension  appara- 
tus, such  as  the  pulley  or  Schneider-Mennel's  frame,  which  were  at 
one  time  very  much  used,  have  become  antiquated.  The  reduction  of 
many  fractures,  such  as  those  of  the  bones  of  the  face  or  through  the 
condyles  in  the  immediate  neighbourhood  of  a  joint,  etc.,  can  be  accom- 
plished simply  by  direct  manipulation,  without  extension  and  counter- 
extension. 

Obstacles  to  Reduction. — Occasionally  various  obstacles  stand  in  the 
way  of  the  successful  reduction  of  a  fracture.  These  include  the  inter- 
p)Osition  of  splinters  of  bone  or  of  soft  parts  between  the  fragments, 
impaction  of  the  broken  ends  in  fractures  of  the  articular  extremities 
of  bones,  and  the  impossibility  of  bringing  sufficient  power  to  bear  upon 
the  fragments.  Impaction  of  the  broken  ends,  such  as  may  occur  in 
fractures  of  the  neck  of  the  femur,  should  be  let  alone,  for  the  reason 
that  the  impaction  favours  consolidation  of  the  fracture. 

Application  of  Retentive  Dressings. — There  are  a  great  number  of 
splints  and  dressings  described  in  §§  53-55  for  holding  the  fragments 
in  their  normal  position  after  they  have  been  brought  into  apposition. 
The  ordinary  dressing  for  a  fracture  is  the  rapidly  hardening  retentive 
appliance  made  of  plaster  of  Paris  (page  217).  Extension  apparatus 
are  generally  used  for  fractures  of  the  thigh,  and  can  also  be  employed 


§  101.]  FRACTURES.  619 

for  tlie  upper  extremity  (see  §  55,  page  230),  while  special  splints  are 
recommended  for  many  fractures,  such  as  those  of  the  lower  end  of  the 
radius.  The  hardening  retentive  dressings  should  be  applied  as  soon 
as  possible,  and  it  very  often  happens  that  subcutaneous  fractures  will 
heal  under  a  single  dressmg.  If  the  swelling  at  the  point  of  fracture 
is  considerable,  ice  can  be  applied  to  the  surface  for  several  days  with 
advantage,  and  then,  after  the  inflammatory  swelling  has  been  reduced, 
the  limb  can  be  placed  in  the  hardening  dressing.  Even  though  the 
swelling  is  marked  the  plaster-of -Paris  dressing  can  be  immediately 
applied,  if  the  parts  are  first  carefully  padded  with  cotton.  In  such 
cases  the  hardening  dressing  has  an  antiphlogistic  effect  from  its  gentle 
and  even  pressure — i.  e.,  it  prevents  an  increase  in  the  swelling.  After 
a  certain  length  of  time  this  dressing  becomes  loose  and  does  not  suffi- 
ciently immobilise  the  point  of  fracture,  and  hence  it  must  be  taken  off 
and  replaced  by  a  new  one.  The  closed  plaster  dressing  should  be 
replaced  as  soon  as  possible  by  one  that  can  be  removed — e.  g.,  one  that 
is  slit  up  in  front  and  provided  with  laces  (plaster  of  Paris,  plaster  and 
glue,  or  plaster  and  water  glass,  etc.),  or  by  a  wooden  splint,  in  order 
that  the  fractured  limb  may  be  massaged  daily  and  the  joints  moved. 
In  putting  on  the  hardening  dressing  great  care  must  be  taken  not  to 
apply  it  too  tightly.  Subsequently  the  fingers  and  toes  should  be  care- 
fully watched,  and  if  they  swell  or  become  bluish-red  or  oedematous,  if 
pain  or  a  feeling  of  numbness  occur,  the  bandage  has  been  applied  too 
tightly  and  must  be  immediately  removed.  Every  plaster-of-Paiis 
dressing,  whenever  it  is  possible,  should  be  again  carefully  inspected 
some  hours  afterwards  to  determine  whether  it  has  not  been  appli(,;d 
too  tightly.  Incurable  ischsemic  muscular  contractures  may  readily 
develop  within  a  few  hours  after  the  apphcation  of  a  plaster- of -Paris 
dressing  which  is  too  tight  (see  page  569),  and  for  these  the  attending 
physician  can  be  held  legally  responsible. 

A  warning  should  be  given  against  the  too  prolonged  use  of  reten- 
tive dressings  and  the  rest  in  bed  which  this  entails,  because  of  the  bad 
effect  produced  upon  the  general  health,  the  atrophy  of  the  muscles, 
the  enforced  disuse  of  the  joints,  etc.  On  account  of  these  serious  pos- 
sibilities, and  particularly  on  account  of  the  danger  of  hypostasis,  old 
people  with  fractures  of  the  lower  extremities  must  often  be  allowed 
to  leave  their  bed  and  go  about  on  crutches  with  a  suitable  splint,  and 
with  a  raised  sole  on  the  shoe  of  the  sound  leg.  Recently  successful 
results  have  been  obtained  by  allowing  all  patients  with  fractures  to 
walk  about  with  suitable  splint  dressings,  and  by  avoiding,  for  the  above- 
mentioned  reasons,  the  treatment  with  dressings  which  require  a  long 
confinement  to  bed.     The  results  are  favourable,  the  time  required  for 


020  INJURIES  AND  SURGICAL   DISEASES   OP   BONE. 

union  is  shortened,  and  the  injurious  effect  of  continenient  in  bed  upon 
the  general  health  is  prevented.  Ambulatory  splints  are  also  very  use- 
ful in  military  surgery.  In  cases  where  it  is  not  advisable  to  employ 
ambulatory  splints  at  once,  the  patient  remains  in  bed  for  four  to  eight 
days,  using  ordinary  splints  or,  in  case  of  the  femur,  an  extension  appara- 
tus. He  is  then  allowed  to  go  about  in  specially  constructed  portative 
splints,  such  as  a  Thomas  hip  splint  (Figs.  -iOT  and  408).  Kraus,  Bar- 
deleben,  and  others  apply  a  closely  fitting  plaster  splint  to  the  extremity, 
which  is  bandaged  with  muslin  or  smeared  with  fat.  In  case  of  fractures 
of  the  feumr  iron  bands  are  included  in  the  plaster  splint,  and  at  the 
upper  end  of  the  latter  a  ring  of  plaster  is  applied  as  a  support  for  the 
tuberosity  of  the  ischium.     My  ambulatory  splints  are  very  simple. 


Fig.  407. — Immobilisation  of  the  hip  in  dis-        Fig.  408. — Thomas  sjilint,  -n-ith  support  at  th& 
ease  of  the  right  hip.  tuberosity  of  the  ischium  and  raised  sole 

under  the  sound  foot,  for  diseases  of  the 
hip  and  knee. 

I  either  use  plaster  or  plaster  and  water-glass  splints,  which  are  remov- 
able— i.  e.,  they  are  slit  up  in  front  and  can  be  laced — or  else  closed  ]3las- 
ter  or  plaster  and  water-glass  splints,  to  which  I  fasten,  either  at  once  or 
the  next  day,  an  iron  stirrup  for  walking  (Fig.  409).     The  stirrup  is  some 


101.] 


FRACTURES. 


621 


distance  from  the  sole  of  tlie  foot,  and  if  a  raised  sole  is  used  on  the 
other  foot  the  patient  can  walk  about  very  comfortably.  This  stirrup 
also  acts  to  extend  the  leg  (Fig.  410).  In  injuries  and  diseases  of  the 
hip  the  pelvis  is  included  in  the  ambulatory  sphnt  (Fig.  411). 

Treatment  of  Subcutaneous  Fractures  involving  a  Joint.— In  subcuta- 
neous fractures  involving  a  joint  special  care  must  be  taken  to  prevent  the 
development  of  anchylosis  or  a  partially  stiff  joint 
(contractures).  This  is  best  accomplished  by  the  use 
of  suitable  splints  or  a  plaster-of -Paris  dressing-,  which 
should  be  frequently  changed — every  five  to  eight 
days,  for  example — and  reapplied  after  altering  the 
position  of  the  joint.  Massage  and  passive  motion 
may  be  combined  with  this— for  example,  at  every 
change  of  dressing.     Extension  appliances  are  very 


Fig.  409. — "  Stirrup  "  for  am- 
bulatory splint. 


Fig.  410. — Ambulatory  splint 
with  iron  stirrup. 


Fig.  411. — Ambulatory  .splint 
of  plastei-  with  iron  stirrup 
for  injuries  and  diseases 
of  the  hip  and  upper  end 
of  the  femur. 


useful,  and  may  be  employed  also,  as  Bardenheuer  has  recently  recom- 
mended, for  fractures  of  the  upper  extremity  which  involve  joints.  If  it  is 
difficult  to  maintain  the  fragments  in  position  after  they  have  been  reduced, 
they  may  be  fastened  together  by  aseptic  steel  nails  or  pins  (see  page  117). 

Treatment  of  Traumatic  Separation  of  the  Epiphysis.— For  securing  bony 
union  after  traumatic  separations  of  the  epiphyses,  the  fragments  should  be 
directly  united  by  long  aseptic  steel  nails  or  pins  (Trendelenburg,  Bruns,  etc.). 
Helferich  has  recommended  long  steel  pins  attached  to  a  removable  handle, 
by  which  they  can  be  slowly  screwed  into  a  bone  ;  they  can  be  used  for  both 
subcutaneous  and  compound  epiphyseal  separations. 

Direct  Fixation  of  the  Fragments  in  Simple  and  Compound  Fractures 
"by  Suturing,  Nailing,  etc. — In  all  subcutaneous  or  compound  fractures, 
where  it  is  difficult  to  maintain  the  fragments  in  proper  position,  the 
wounded  bone  surfaces  can  be  held  in  contact  by  sutures  of  silver  wire, 
or,  better,  of  aluminium-bronze  wire,  by  nails,  ivory  pegs,  steel  pins, 
Gussenbauer's  or  Parkhill's  clamps,  or  by  bone  rings  (Senn),  as  de- 
scribed on  page  118  (Union  of  Bone  Surfaces).     In  this  category  belong 


622  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

Malgaigne's  hooks  for  fracture  of  the  patella  and  Malgaigne's  pin  for 
fracture  of  the  tibia — instruments  which  are  scarcely  ever  used  at 
present.  If  nails  are  to  be  used  to  secure  fixation  of  the  bones,  long 
four-cornered  steel  ones  should  be  employed.  These  are  pohshed, 
boiled  for  fifteen  minutes  in  a  one-per-cent.  soda  solution,  heated  red- 
hot,  and  placed  in  a  ten-per-cent.  solution  of  carbolic  acid  in  glycerine, 
after  which  they  are  perfectly  sterile.  After  the  bones  have  been 
nailed  together  they  are  securely  immobilised.  The  wounds  in  com- 
pound fractures  are  not  sutured,  but  packed  with  sterilised  gauze.  The 
nails  are  removed  about  the  beginning  of  the  fourth  week. 

The  Treatment  of  Compound  Fractures. — The  treatment  of  com- 
pound fractures  has  been  totally  changed  by  the  antiseptic  method 
of  treating  wounds,  and  the  results  which  we  now  obtain  are  very 
satisfactory.  Typical  cases  of  compound  fracture  which  run  an  asep- 
tic course  heal  without  pain  and  without  fever ;  the  discharge  from 
the  wound  is  slight,  and  we  are  certain  of  being  able  to  prevent  suppu- 
ration. The  sj)lints  used  are  in  general  the  same  as  in  simple  fractures, 
particularly  fenestrated  plaster  splints,  and  the  ambulatory  splints  de- 
scribed on  page  620. 

The  technique  of  the  antiseptic  treatment  of  the  wound  varies  with 
the  kind  of  case.  For  this  reason  we  distinguish  three  classes  of  cases : 
1.  The  perfectly  fresh  fractures  in  which  the  wound  is  the  result  of  a 
perforation  of  the  skin  by  a  fragment.  2.  The  ordinary  severe  cases 
of  compound  fracture.  3.  The  compound  fractures  which  are  not 
recent  and  have  already  become  infected. 

1.  Treatment  of  Fresh  Fractures  with  Transfixion  of  the  Skin  by  a 
Fragment. — The  antiseptic  management  of  a  perfectly  fresh  fracture 
complicated  with  a  perforation  of  the  skin  by  a  fragment  is  as  follows : 
We  will  suppose  that  we  have  to  deal  with  a  fractm'e  accompanied  by 
only  a  small,  still  bleeding  cutaneous  wound,  similar  to  a  punctured 
wound ;  that  the  case  comes  under  observation  immediately  or  within, 
a  few  hours  after  the  reception  of  the  injury;  that  there  is  no  large 
extravasation  of  blood  present ;  that  the  bone  is  simply  broken,  and  not 
splintered  ;  and  that  no  infection  has  occurred.  In  such  cases  enlarge- 
ment of  the  wound  and  drainage  can  be  omitted.  After  disinfection 
of  the  wound  and  surrounding  parts,  as  described  in  §  6  and  §  32,  the 
wound  is  covered  with  an  aseptic  dressing,  such  as  sterilised  gauze^ 
folded  together  into  several  layers,  and  cotton,  wool,  or  pads  filled 
with  moss.  Should  the  wound  have  become  closed  by  a  dried  blood- 
clot  and  no  indications  of  infection  be  present,  this  scab  can  be  left  un- 
disturbed and  the  fracture  allowed  to  heal  under  it.  A  plaster-of-Paris 
dressing  can  then  be  immediately  applied  over  the  aseptic  dressing. 


§  101.]  FRACTURES.  62S 

This  aseptic  plaster-of -Paris  occlusive  dressing  is  left  in  place,  if  no 
fever  or  pain  in  the  wound  occurs,  for  two  or  tliree  weeks  longer,  until 
the  wound  has  healed,  and  is  then,  if  necessary,  replaced  by  a  simple 
plaster- of- Paris  dressing  until  complete  consolidation  of  the  fracture 
has  taken  place.  This  aseptic  plaster-of -Paris  occlusive  dressing  haa 
been  recently  very  much  employed  for  fresh  compound  fractures  with 
small  wounds,  and  also  in  the  treatment  following  osteotomies  of  the 
rhachitic  extremities  of  children.  Bergmann,  Peyher,  and  others  ob- 
tained brilliant  results  in  the  Turko-Russian  War  with  this  same  form 
of  dressing,  even  in  such  injuries  as  gunshot  wounds  of  the  knee. 
The  method  is  not  suitable  for  severe  compound  fractures  with  exten- 
sive wounds  of  the  soft  parts,  nor  for  cases  which  are  not  perfectly 
fresh  when  they  come  for  treatment. 

The  opinions  of  surgeons  still  differ  as  to  whether  the  aseptic  occlu- 
sion carried  out  in  the  manner  above  described  should  likewise  be  used 
for  fresh  comminuted  fractures  with  a  small  cutaneous  wound,  or 
whether  the  wound  should  be  enlarged  and  the  splinters  extracted. 
At  all  events,  the  brilliant  results  obtained  by  Bergmann  and  Reyher 
in  the  Turko-Russian  War  show  that  the  primary  extraction  of  the 
fragments,  formerly  so  much  insisted  upon  in  comminuted  fractures,  is 
not  always  necessary ;  that  the  above-described  simple  aseptic  occlu- 
sion, without  enlarging  the  wound  and  without  extraction  of  the  frag- 
ments, gives  even  here  excellent  results ;  and  that  the  splinters,  though 
very  numerous,  are  capable  of  healing  up  completely  in  the  wound, 
provided  the  latter  runs  an  aseptic  course.  If  the  wound  suppurates,, 
the  splinters  of  bone  will  then  not  heal  in  and  will  have  to  be  removed. 

2.  The  Antiseptic  Management  of  Severe  Compound  Fractures,  with 
extensive  injury  to  the  soft  parts,  likewise  consists  in  a  thorough  disin- 
fection of  every  portion  of  the  wounded  surface  and  of  the  surround- 
ing parts  to  a  considerable  distance  from  the  wound.  If  the  opening 
is  not  large  enough  to  permit  of  careful  examination  or  disinfec- 
tion of  the  entire  wound  cavity,  it  should  be  enlarged  with  the  knife, 
using  for  the  extremities  an  Esmarch  bandage.  The  point  of  frac- 
ture is  inspected,  and  the  entire  cavity  of  the  wound  is  energetically 
irrigated  with  a  one-tenth-per-cent.  solution  of  bichloride  of  mercury, 
crushed  shreds  of  tissue  are  cut  off  with  the  scissors  and  forceps,  the 
hsemorrhage  carefully  arrested,  foreign  bodies,  bullets,  etc.,  are  removed, 
and  long,  deep  pockets  under  the  skin  or  deeper  parts  are  slit  open.  If 
necessary,  the  fragments  may  be  drawn  out  of  the  wound  with  sharp 
hooks  or  bone  forceps,  to  render  it  possible  to  systematically  examine 
and  disinfect  them  and  "the  soft  parts  lying  behind  them.  Counter- 
openings  are  made  for  the  admission  of  short,  large-sized  drainage  tubea 


62J:  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

to  the  most  deeply  lying  parts,  and  every  niclie,  every  recess  in  the 
wound,  and  every  pocket,  should  be  carefully  drained  or  slit  open.  The 
deep  drains  should  always  extend  to  the  cleft  in  the  bone,  but  should 
not  lie  between  the  fragments.  Packing  the  wound  with  iodoform 
gauze  or  sterilised  mull  su])plies  excellent  drainage.  If  splinters  are 
present,  all  those  which  are  entirely  loose  and  dead  should  be  removed, 
while  those,  on  the  other  hand,  which  are  still  alive  and  attached  to 
the  periosteum  should  be  retained,  and,  if  displaced,  returned  to  their 
normal  position.  Projecting  points  on  the  fragments  which  interfere 
with  reduction  should  be  removed  with  the  bone  forceps  or  saw.  If 
it  is  difficult  to  maintain  the  fragments  in  position  after  their  reduc- 
tion, they  may  be  secured  in  their  normal  situation  by  sutures  through 
the  ends  of  the  bone,  or  by  nailing  them  together  aseptically  (see 
page  621). 

After  the  wound,  with  all  its  recesses,  has  been  very  carefully  dis- 
infected and  drained,  we  proceed  to  insei*t  the  sutures,  provided  the 
case  is  one  suited  for  primary  union.  I  believe  it  is  ^viser  not  to  suture 
wounds  of  this  kind,  but  to  leave  them  open  and  pack  them  with  iodo- 
form gauze  and  sterilised  mull,  over  which  is  placed  an  antiseptic  pro- 
tective dressing. 

Resection  of  the  Broken  Ends. — Formerly,  in  the  case  of  com]3ound 
comminuted  fractures  of  the  long  hollow  bones,  the  splintered  ends  of 
the  bone  were  frequently  removed  (so-called  resection  in  continuity). 
This  primary  resection  immediately  after  the  injury  is  only  applicable 
to  the  most  severe  cases.  If,  during  the  subsequent  course  of  com- 
pound comminuted  fractures,  necrosis  of  the  broken  ends  takes  place, 
then  secondary  resection  of  the  fragments  is  indicated  to  obtain  more 
rapid  healing. 

Treatment  of  Compound  Fractures  of  Joints. — If  we  have  to  deal  with 
a  compound  fracture  of  a  joint,  we  proceed  according  to  the  same  prin- 
ciples— i.  e.,  the  joint  is  exposed  by  a  sufficiently  long  incision,  carefully 
disinfected,  and  drainage  provided  for.  When  necessary,  we  also  re- 
move any  crushed  fragments  of  bone,  extract  the  free  splinters,  or,  in 
the  severest  cases,  perform  total  resection  of  the  articular  ends  of  the 
bones.  Speaking  generally,  resection  in  compound  fractures  of  a  joint 
is  governed  by  the  following  principles  (see  §  40)  :  Primary  resection  is 
indicated  in  fresh,  non -infected,  extensively  comminuted  fractures  of 
the  articular  ends  of  the  bones,  accompanied  by  gi-eat  injury  to  the  soft 
parts.  Compound  fractures  involving  a  joint  with  only  a  small  cuta- 
neous wound,  after  careful  disinfection  of  the  latter,  should  be  treated 
at  first  as  though  the  fracture  were  subcutaneous.  If  the  attempt  fails, 
and  inflammation  or  suppuration  of  the  joint  with  fever  comes  on,  then 


§  101.]  FRACTURES.  625 

arthrotomy  should  be  performed — i.  e.,  the  joint  is  opened  freely,  the 
fracture  exposed,  carefully  disinfected,  and  drained.  Not  infrequently, 
under  these  conditions,  fixation  of  the  fragments  by  sutures  or  nails 
renders  excellent  service.  Whether  a  typical  resection  of  the  broken 
articular  extremities  should  be  performed  depends  upon  the  character 
and  severity  of  the  injury  to  the  bone  and  the  extent  of  suppuration  or 
infection.  At  all  events,  resection  is  indicated  when  fever  and  local 
inflammation  continue  after  arthrotomy  and  drainage  of  the  joint,  and 
when  there  is  a  probability  of  a  severe  infection  of  the  wound  of  the 
bone  having  taken  place. 

Subsequent  Treatment  of  Compound  Fractures. — The  rest  of  the  treat- 
ment of  compound  fractures  depends  upon  their  subsequent  behaviour. 
In  the  most  favourable  cases,  running  a  course  free  from  fever,  the 
first  dressing  is  left  in  place  six  to  eight  to  ten  to  fourteen  days  and 
then  changed,  and  at  the  same  time  any  drains,  sutures,  or  tampons  are 
removed.  If,  on  the  other  hand,  fever  should  occur,  or  the  patient 
complain  of  pain  in  the  wound,  the  dressing  should  be  immediately 
changed  and  the  wound  and  parts  surrounding  it  carefully  examined 
for  the  presence  of  retained  discharges,  which  should  be  immediately 
let  out  by  an  incision.  The  granulating  wound  should  also  be  treated 
strictly  according  to  antiseptic  principles,  and  a  closed  or  fenestrated 
plaster  splint,  or  one  of  the  modifications  given  under  §  54,  applied  un- 
til the  wound  has  become  covered  with  skin.  "We  cover  large  granulat- 
ing surfaces  with  skin  by  Thiersch's  method  of  skin  grafting.  When 
the  wound  has  healed,  a  closed  plaster  splint  is  applied,  if  necessary, 
until  consolidation  of  the  fracture  is  complete. 

3.  Treatment  of  Fractures  which  are  not  Fresh  and  have  become 
Septic, — We  count  all  cases  as  not  "  fresh  "  which  come  under  obser- 
vation twenty-four  to  forty-eight  hours  after  the  injury,  with  already 
existing  local  inflammatory  changes  in  the  wound.  Of  course,  the 
character  of  these  cases  varies  greatly,  according  to  the  severity  and 
nature  of  the  reaction  which  is  present  in  the  wound.  If  the  reaction 
in  the  wound  is  slight,  an  aseptic  course  of  repair  may  not  infrequently 
be  obtained  by  energetically  disinfecting,  enlarging,  and  draining  the 
wound  and  then  applying  an  antiseptic  occlusive  dressing.  Packing 
the  cavity  of  the  wound  with  iodoform  gauze  or  sterilised  mull,  and 
omitting  all  sutures,  is  a  procedure  particularly  applicable  for  such 
cases. 

In  other  instances,  again,  the  reaction  in  the  wound  will  have 
already  become  very  marked.  There  is  pronounced  decomposition 
and  putrefaction  of  the  discharges,  and  the  crushed  soft  parts  and  cel- 
lular tissue  are  gangrenous,  and  saturated  with  the  products  of  decom- 


026  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

position.  The  suppuration  and  putrefaction  which  are  present  are  no 
longer  hmited  to  the  wound,  but  have  begun  to  spread  progressively, 
JS^ot  infrequently  there  is  such  a  large  accumulation  of  putrefactive 
gases  that  a  pronounced  gaseous  infiltration  (emphysenia)  takes  place. 
Even  in  such  unfavourable  cases  of  pronounced  sepsis  a  vigorous  disin- 
fection of  all  the  septic  tissues  should  be  undertaken  and  incisions 
made  in  great  numbers.  We,  of  course,  avoid  apjjlying  the  ordinary 
closed  protective  dressings  which  exert  pressure,  and  content  ourselves 
with  energetic  disinfection  of  the  wound,  covering  it  with  sterilised 
gauze  or  iodoform  gauze,  or  employing  permanent  antiseptic  iri-igation 
(see  page  181).  As  long  as  the  treatment  lasts  it  is  exceedingly  impor- 
tant to  keep  the  extremity  in  an  elevated  position  and  the  fragments  as 
securely  immobilised  as  possible.  When  the  wound  has  become  aseptic 
and  is  granulating,  we  cover  it  with  iodoform  gauze  and  cotton  and 
immoI)ilise  the  fragments  by  a  suitable  splint,  or  by  a  fenestrated  or 
interrupted  plaster-of-Paris  dressing.  The  treatment  of  compound 
fractures  which  have  become  infected  demands  much  patience  and 
care,  and,  above  all,  experience.  It  is  very  important  to  note  the  be- 
haviour of  the  temperature  by  means  of  the  constant  use  of  the  ther- 
mometer, and  to  recognise  any  retention  of  discharges  at  the  earliest 
possible  moment  and  to  let  them  out  by  incisions. 

Indications  for  Amputation  and  Disarticulation.— In  what  cases  of  com- 
pound fractui'e  should  amputation  or  disarticulation  of  the  injured  limb  be 
performed  ?  Immediate  amputation  or  disarticulation  of  the  injured  limb 
directly  after  the  reception  of  the  injury,  or  within  the  first  twenty-four  to 
forty-eight  hours,  before  the  reaction  in  the  wound  sets  in,  is  only  indicated 
in  cases  of  very  severe  crushing  of  the  bone  with  extensive  injury  to  the 
soft  parts  (primary  amputation).  With  the  aid  of  the  antiseptic  method  of 
treating  wounds  we  are  enabled  to  carry  out  conservative  treatment  success- 
fully in  cases  where  formerlj^  preservation  of  the  injured  limb  Avould  have 
been  impossible.  The  opening  of  a  large  joint  or  injury  of  large  arteries  and 
nerves  do  not  in  themselves  indicate  primary  amputation,  though  it  should 
be  immediately  performed  if  the  soft  parts,  muscles,  vessels,  and  nerves  are  so 
extensively  lacerated  and  crushed  that  preservation  of  the  limb  is  impossible 
or  gangrene  is  sure  to  follow.  The  decision  as  to  whether  amput:ition 
should  be  immediately  performed  or  not  is  not  always  easy.  After  having 
determined  upon  amputation,  we  perform  it  through  sound  tissues  Avhich 
have  not  been  crushed,  and  take  the  greatest  care  to  avoid  fashioning  the 
flaps  which  are  to  cover  the  amputation  wound  from  the  contused  portions 
of  skin  or  those  portions  that  have  been  torn  loose  from  the  underlying  parts. 

Amputation  is  also  indicated  in  the  case  of  many  infected  compound 
fractures  when  the  local  wound  infection,  the  suppuration,  putrefaction, 
etc.,  have  become  so  extensive  as  to  render  preservation  of  the  limb  impos- 
sible, or  when  severe  manifestations  of  general  septic  infection  make  their 
appearance.     In  such  cases  we  amputate— in  other  words,  we  remove  the 


§  101.]  FRACTURES.  627 

source  of  infection  in  order  to  save  the  life  of  the  patient.  Delay  in  such 
cases  is  dangerous,  and  the  sooner  amputation  is  performed  in  the  presence 
of  high,  septic  fever,  the  better  is  the  prospect  of  recovery.  In  the  later 
stages  of  compound  fractures  amputation  is  indicated,  especially  when  there 
is  extensive  suj)purative  inflammation  of  the  medulla  of  the  bone  or  of  the 
joints,  or  when  the  patient  is  in  danger  of  exhaustion  from  severe  suppura- 
tion, etc.  Briefly  speaking,  we  amputate  when  the  condition  of  the  extrem- 
ity is  such  that  healing  cannot  be  expected  from  conservative  treatment. 

After-treatment  of  Fractures. — The  after-treatment  is  directed  prin- 
cipally towards  the  disturbances  in  nutrition  which  occur  in  the  soft 
parts,  particularly  the  skin,  muscles,  and  joints.  Yerj  often  no  special 
after-treatment  is  necessary  when  consolidation  of  the  fracture  is  com- 
pleted. Massage,  diligent  exercise  of  the  muscles,  and  active  and 
passive  motion  of  the  joints  will  usually  soon  remedy  the  muscular 
weakness  and  the  stiffness  of  the  joints,  and  the  sooner  these  measures 
are  adopted  the  better.  A  warning  should  be  given  against  the  too 
protracted  use  of  retentive  dressings  for  fractures,  on  account  of  the 
atrophy  of  the  muscles  and  the  disturbances  in  the  functions  of  the 
joints  which  they  cause.  In  the  case  of  old  people  particularly  it  is 
often  necessary  to  give  up  the  confinement  to  bed  because  of  the  threat- 
ening hypostasis  or  disturbance  of  the  general  health,  and  to  permit 
them  to  move  about,  even  with  fractures  of  the  lower  extremity,  in 
ambulatory  splints  (see  pages  620  and  621).  In  proper  cases,  such  as 
in  fractures  of  the  radius  with  the  ulna  intact,  or  of  the  fibula  with 
the  tibia  intact,  massage  can  be  done  at  a  very  early  period — within 
the  first  or  second  week,  for  instance — and  a  more  rapid  recovery 
will  thus  be  obtained.  Of  course,  the  above-mentioned  fractures  must 
be  immobilised  a  long  enough  time — two  to  three  weeks  at  least — by 
proper  splints.  Baths  and  rubbing  with  alcohol  are  also  of  use.  If 
there  is  much  oedema,  particularly,  for  example,  in  the  case  of  the 
lower  extremity,  the  latter  should  be  enveloped  in  a  tight  flannel 
bandage,  or  retentive  dressings  which  can  be  readily  removed  should 
be  applied  (Figs.  225,  232).  If  a  long  timiO  has  elapsed  since  consoli- 
dation of  a  fracture  of  an  extremity,  and  if  the  stiffness  of  the  joints 
and  atrophy  of  the  muscles,  owing  to  Tack  of  energy  on  the  part  of  the 
patient  or  physician,  have  become  very  pronounced,  it  is  all  the  more 
difficult  to  restore  the  normal  function.  In  such  cases  it  is  sometimes 
best  to  repeatedly  ansesthetise  the  patients  for  the  purpose  of  moving 
the  joints  and  performing  vigorous  massage.  It  is  in  just  these  cases 
that  massage  not  infrequently  yields  most  brilliant  results.  In  these 
old  cases,  where  motion  is  impaired  and  there  are  contractures  and 
muscular  atrophy,  methodical  exercises  by  means  of  the  mechanical 
appliances  in  the  orthopaedic  institutes  are  exceedingly  valuable.    If  we 


628  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

have  to  deal  with  ischremic  contractures  and  paralyses,  tliey  should  be 
treated  according  to  the  rules  mentioned  on  page  5 TO. 

Treatment  of  the  Complications. — The  treatment  of  the  above-men- 
tioned complications  is  descriljed  in  previous  paragraphs — shock  in  §  63, 
delirium  tremens  in  §  6-4,  infectious  diseases  of  wounds  in  §§  66-75, 
and  gangrene  in  §  100,  etc. 

Treatment  of  Delayed  Callus  Formation  and  Pseudarthrosis. — For 
these  conditions  the  following  methods  are  particularly  valuable  :  1. 
Rubbing  together  the  ends  of  the  bones  (Celsus),  according  to  Karmi- 
low,  was  successful  only  forty  times  in  four  hundred  and  thirty  cases. 
In  this  method,  which  is  suited  more  for  cases  with  delayed  callus  for- 
mation, the  fragments  are  rubbed  together  daily  until  a  sufficient  local 
reaction  has  set  in  and  the  point  of  fracture  is  tender  on  pressure.  A 
plaster-of -Paris  dressing  is  then  apj)lied.  Patients  with  fracture  of  the 
lower  extremity  can  be  allowed  to  move  about  in  a  retentive  dressing 
for  the  purpose  of  maintaining  an  inflammatory  irritation  at  the  point 
of  fracture.  These  ambulatory  splints  often  bring  about  a  prompt 
result.  2.  Artificial  increase  of  bone  formation  by  the  production  of 
a  venous  hyperemia  at  the  point  of  fracture  by  tying  off  the  extrem- 
ity on  the  proximal  side  of  the  fracture  with  a  rubber  tourniquet  drawn 
moderately  tight.  In  order  that  the  hypersemia  may  be  localised  at  the 
point  of  fracture  the  extremity  above  and  below  it  can  be  enveloped  in 
a  bandage  (Dumreicher,  Helferich,  etc.).  The  procedure  can  be  com- 
bined with  the  application  of  a  plaster  or  other  kind  of  splint,  and  it  is 
he-re  also  a  good  plan  to  permit  patients  with  fractui'e  of  the  lower 
extremity  to  move  about  in  a  proper  dressing.  3.  Le  Fort  has  suc- 
cessfully employed  electrolysis — i.  e.,  two  platinum  needles  connected 
with  a  constant  battery  are  stuck  into  the  false  joint.  The  needle 
fastened  to  the  positive  iDole  is  kept  in  one  place,  while  that  fastened 
to  the  negative  pole  is  introduced  repeatedly  at  several  different  points. 
4.  The  employment  of  various  other  means  of  irritation  has  been  aban- 
doned (irritation  of  the  skin,  subcutaneous  injections  of  irritating 
chemical  liquids,  etc.).  Nevertheless,  Mikulicz  has  used  oil  of  tur- 
pentine with  excellent  results.  After  making  a  longitudinal  incision 
through  the  soft  parts  and  periosteum,  the  latter  is  freed  from  almost 
the  entire  circumference  of  the  bone  with  the  raspatory  to  a  distance 
of  about  ten  centimetres  from  the  point  of  fracture,  and  gauze  satu- 
rated with  oil  of  turpentine  is  placed  between  the  bone  and  periosteum 
and  changed  every  three  to  five  days  until  the  wound  has  healed.  As 
yet,  Bergmann  has  seen  no  case  of  pseudarthrosis  cured  by  the  oil-of- 
turpentine  treatment.  5.  Irritation  of  the  ends  of  the  bones  by  driv- 
ing ivory  pegs  into  them  (Diefienbachj  is  performed  in  the  following 


§101.]  FRACTURES.  629 

manner  :  After  the  soft  parts  above  and  below  the  point  of  fracture 
have  been  divided  with  the  knife,  holes  are  bored  in  the  bone  with  a 
drill,  and  one  or  two  ivorj  pegs,  according  to  the  size  of  the  bone,  are 
driven  into  each  fragment.  The  extremity  is  then  encased  in  a  plaster 
dressing,  which  may  be  fenestrated  or  not.  The  ivory  pegs  are  allowed 
to  remain  two  to  three  weeks  or  longer.  Karmilow  states  that  the  pro- 
cedure when  applied  to  the  thigh  and  arm  has  been  successful  in  43.5 
per  cent,  of  the  cases,  while  for  the  leg  and  forearm  the  number 
of  cures  has  amounted  to  eighty  per  cent.  Instead  of  ivory  23egs, 
Riedinger  has  recommended  bone  pegs,  which  are  capable  of  becom- 
ing firmly  adherent  to  the  bones. 

If  the  procedures  hitherto  described  do  not  prove  successful,  there 
is  nothing  left  but  to  expose  the  false  joint  with  the  knife,  to  freshen 
the  ends  of  the  bones,  to  resect  them,  and  then,  when  necessary,  to 
fasten  them  together  by  sutures  of  catgut,  sterilised  silver  wire, 
aluminium-bronze  wire,  silkworm  gut,  or  by  nails.  The  ends  of  the 
bones  can  be  freshened  by  resecting  them  in  the  form  of  steps  and 
thus  fitting  them  together ;  or  the  pointed  end  of  one  fragment  can  be 
introduced  into  the  medullary  cavity  of  the  other  (see  page  118,  Fig. 
111).  Exposure  of  the  false  joint,  followed  by  freshening  the  ends  of 
the  bones  and  uniting  them  with  sutures  or  nails,  is  the  safest  method 
of  treating  all  false  joints  of  long  standing,  and  if  carried  out  with 
antiseptic  precautions  it  is  entirely  free  from  danger.  For  nailing  the 
bones,  we  use,  as  was  said  before,  long,  four-cornered  steel  nails,  which 
are  rendered  perfectly  sterile  by  pohshing,  boiling  for  fifteen  minutes 
in  a  one-per-cent.  soda  solution,  heating  red-hot,  and  storing  in  a 
ten  per-cent.  solution  of  carbolic  acid  in  glycerine.  After  nailing 
the  bones  together,  an  antiseptic  protective  dressing  is  placed  over 
the  wound,  which  is  left  open,  and  a  plaster  dressing  is  applied  on 
the  outside.  The  nails,  which  should  protrude  for  a  suflicient  dis- 
tance from  the  soft  parts,  are  removed  at  the  end  of  the  third  or 
beginning  of  the  fourth  week.  Instead  of  nails,  long  steel  23ins  can 
be  used  in  suitable  cases,  or  Gussenbauer's  clamps,  or  metallic  or  bone 
rings. 

If  a  considerable  loss  of  substance  has  occurred  in  one  of  the  two 
bones  of  the  forearm  or  leg,  we  may  either  chisel  out  of  the  other 
bone  a  piece  corresponding  in  size  to  the  defect,  and  cause  the  ends 
of  the  bones  to  unite,  with  a  corresponding  amount  of  shortening, 
or  the  defect  may  be  repaired  by  one  of  the  usual  methods  of  osteo- 
plasty (see  pages  607  and  610).  In  one  case  of  loss  of  substance  in 
the  tibia  Hahn  successfully  implanted  the  lower  portion  of  the  fibula 
into  the  upper  fragment  of  the  tibia.      Quenu,  Thiriai',  and   others 


630 


INJURIES  AND  SURGICAL   DISEASES  OF   BONE. 


liave  successfully  employed  aluminium  splints  for  pseudarthrosis ;  they 
were  on  the  average  ten  centimetres  in  length,  and  were  fastened  sub- 
periosteally  by  four  to  six  screws.  Bony  union  was  obtained  in  five 
cases,  and  in  three  of  these  every  other  method  of  operative  treatment 
had  been  unsuccessful.  In  two  cases  the  splint  healed  in  permanently, 
and  in  three  it  had  to  be  removed. 

The  internal  administration  of  lime,  or,  what  is  better,  of  phos- 
phorus (Wegner),  has  been  recommended  for  pseudarthrosis.  Any 
constitutional  or  local  anomaly  which  may  be  present  must  always,  of 
course,  be  taken  into  consideration. 

If  all  methods  of  treatment  prove  unsuccessful,  care  must  be  taken 
to  alleviate  the  disturbance  of  function,  as  far  as  possible,  by  a  suitable 
splint  apparatus.  If  the  peripheral  portion  of  the  limb  has  become  so 
atrophic  and  fiail-like  as  to  render  the  wearing  of  a  supporting  appli- 
ance scarcely  possible,  amputation,  particularly  if  it  is  the  lower  extrem- 
ity which  is  involved,  is  indicated. 

The  Erosion  of  an  Ivory  Peg  which  has  been  driven  into  a  Bone.— It  is 

well  known  that  ivory  pegs  which  have  been  driven  into  a  bone  become 
roughened  and  appear  as  though  portions  of  their  surface  had  been  gnawed 

away  (Fig.  412).  Polynuclear 
giant  cells  are  found  in  the 
small  cavities,  and  the  same 
osteoclasts  which  are  present 
during  the  normal  process  of 
bone  absorption.  The  cause 
of  this  lacunar-bone  absorp- 
tion is  partly  to  be  ascribed 
to  the  action  of  an  acid  and 
partly  to  the  pressure  of  the 
vessels  and  the  cells  of  the 
surrounding  tissues.  I  have 
shown  that  it  is  probably  the 
carbonic  acid  which,  in  statu 
nascendi.  during  the  metabo- 
lism of  the  tissues,  sets  free  the  lime  in  tlie  ivory  peg,  and  that  then  the  decal- 
cified ground  substance  which  is  left  behind  is  dissolved  by  the  alkaline 
fluids  in  the  tissues  (see  page  583). 

The  Treatment  of  Fractures  which  have  healed  with  Deformity. — 
Deformity  in  the  healing  of  a  fracture  should  be  prevented  by  careful 
supervision  of  the  point  of  fracture,  or,  in  other  words,  of  the  position 
of  the  fragments  while  the  process  of  healing  is  going  on.  The  splints 
should  be  changed  too  often  rather  than  too  infrequently.  If  a  frac- 
ture heals  with  so  marked  a  displacement  as  to  produce  serious  disturb- 
ance of  function,  the  bones  should  either  be  refractured,  or  the  point 


HHIi-' 


^Jiiiili': 


Fig.  412. — Erosion  (a;  '>!  ;in  ivory  peg  by  the  action  of 
carbonic  acid. 


g  102.]  CONTUSIONS  AND   WOUNDS   OF  BONE.  631 

of  fracture  exposed,  chiselled  through,  and  the  ends  of  the  bones  then 
reunited  in  a  good  position.  Those  cases,  as  a  general  thing,  are  least 
amenable  to  treatment  which  have  healed  with  considerable,  dislooatio 
ad  longitudinem.  The  bones  are  broken  under  chloroform  ansesthesia 
either  by  hand  or  by  some  special  apparatus.  The  instruments  used 
for  directly  fracturing  the  bones  ai*e  called  osteoclasts  ;  the  ones  invented 
by  Rizzoli  and  by  Collin  and  Robin  are  very  useful  (see  page  91).  The 
open  division  of  fractures  which  have  healed  with  deformity  is  carried 
out  by  making  an  incision  through  the  soft  parts,  thus  exposing  the 
points  of  fracture,  and  then  dividing  the  bone  with  the  hammer  and 
chisel  (osteotomy).  The  bone  is  not  chiselled  entirely  through,  but  a 
small  portion  is  left,  which  is  broken  by  hand.  When  necessary,  a 
wedge-shaped  piece  must  be  chiselled  out  of  the  deformed  bone.  Os- 
teotomy of  the  bone  is  absolutely  free  from  danger  if  the  rules  of  asep- 
sis are  carefully  observed.  The  wound  is  not  sutured,  but  left  open 
and  packed  with  sterilised  gauze,  and  directly  over  the  protective  dress- 
ing a  plaster  splint  is  applied,  which  is  left  in  place  until  the  wound 
has  healed,  though  it  is  changed  earlier  if  there  is  need  of  doing  so.  In 
cases  of  considerable  shortening  from  mal-union  of  a  fracture,  the  use 
of  extension  by  a  weight,  after  performing  osteotomy,  is  very  much  to 
be  recommended.  Badly  united  fractures  of  the  femur,  for  instance, 
occurring  in  adults  and  accompanied  by  much  shortening,  sometimes 
require  powerful  extension  (by  a  weight  amounting  to  twenty  to  twenty- 
five  to  thirty  pounds),  and  surprisingly  good  results  may  be  obtained, 
as  both  Schede  and  myself  have  observed.  Under  certain  circum- 
stances Schede  recommends  increasing  the  weight  used  for  extension 
in  the  case  of  adults  to  as  much  as  forty  pounds. 

Moritz  and  Meyer  have  used  the  electric  current  with  success  for 
exuberant  callus  (callus  luxurians). 

§  102.  Contusions  and  Wounds  of  Bone. — If  a  bone  is  crushed  by  a 
blow  from  a  blunt  object,  we  have  especially  to  consider,  in  addition  to 
the  contusion  of  the  bone  substance,  the  injury  to  the  overlying  soft 
parts,  the  skin,  the  subcutaneous  cellular  tissue,  and  the  periosteum. 
The  course  of  contusions  of  the  soft  parts  is  described  in  §  92.  Con- 
tusions of  periosteum  lead  to  a  greater  or  less  extravasation  of  blood 
into  and  particularly  beneath  the  periosteum,  which  is  called  a  hgema- 
toma  of  the  periosteum.  These  periosteal  and  subperiosteal  extravasa- 
tions of  blood  usually  terminate  by  being  gradually  absorbed,  l^ot 
infrequently  there  develops,  at  the  point  where  the  periosteum  has 
been  contused,  a  traumatic,  ossifying  periostitis,  in  consequence  of 
which  the  bone  becomes  temporarily  thickened. 

The  anatomical  changes  which  occur  in  contusions  of  bone  tissue 


632  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

proper  consist  in  a  more  or  less  pronounced  compression  or  splintering 
of  the  bone  substance,  such  as  happens  after  a  thrust  or  blow,  and  to  a 
marked  degree  in  every  fracture.  In  the  medullary  cavity  an  extrava- 
sation of  blood  is  found  proportionate  in  extent  to  the  amount  of  vio- 
lence exhibited.  As  is  the  case  with  fractures,  the  course  of  contusions 
of  the  periosteum,  bone,  and  medullary  tissue  depends  mainly  upon 
whether  an  external  wound  is  present  or  not.  Only  in  the  most  ex- 
ceptional instances  of  subcutaneous  contusions  of  bone  do  inflannnatory 
or  suppurative  processes  occur,  and  when  they  do  it  is  owing  to  the 
deposit  of  micro-organisms  from  the  blood  in  the  contused  portions  of 
bone  and  medullary  tissue,  or  to  the  extension  to  the  deeper  parts  of 
inflammatory  processes  beginning  in  the  contused  skin.  Primary  acute 
infectious  osteomyelitis  is  probably  sometimes  caused  by  such  a  contu- 
sion of  the  medullary  and  cortical  tissue.  It  is  a  well-known  fact  that 
tuberculosis  may  originate  from  some  slight  contusion  of  the  bone, 
particularly  in  the  case  of  children,  for  the  reason  that  the  tubercle 
bacillus  finds  in  contused  tissues  and  extravasations  of  blood  conditions 
which  are  favourable  to  its  development.  The  vascular  arrangement 
in  the  medulla  is  such  that  solid  impurities  in  the  blood  readily  become 
deposited.  The  inflammation  of  bone  to  which  mother-of-pearl  turners 
are  subject  is  an  instance  of  this  (see  page  642). 

The  treatment  of  subcutaneous  contusions  of  periosteum  and  bone 
consists  at  first  in  placing  the  injured  part  in  a  suitable  (elevated)  posi- 
tion, in  the  application  of  ice,  and  later  in  employing  massage  to  pro- 
mote absorption  of  the  blood  extravasated  in  the  periosteum  and  soft 
parts.  Inflammatory  complications,  suppuration,  etc.,  are  treated  ac- 
cording to  the  general  rules  laid  down  in  §§  68-Tl. 

Open  Wounds  of  Bone. — The  open  wounds  of  bone  have  lost  the 
dano-er  that  used  to  attend  them  before  the  introduction  of  the  antisep- 
tic method  of  treating  wounds.  By  the  latter  means  all  infection  is 
avoided,  and  even  deep  wounds  which  penetrate  into  the  medullary 
cavity  heal  without  complications.  The  most  common  wounds  of  bone 
are  those  occurring  in  fractures.  True  wounds  of  bone  are  such  as 
are  caused  by  a  blow,  or  a  thrust  with  a  sabre,  knife,  axe,  etc.  In  con- 
sequence of  this  violence  there  may  be  produced  in  the  skull,  for  ex- 
ample, the  fissures  or  cracks  mentioned  under  Incomplete  Fractures, 
which  divide  the  bone  either  partially  or  completely.  On  the  extremi- 
ties, particularly  the  fingers,  complete  division  of  the  bone  and  soft 
parts  is  frequently  observed.  Kow  and  then,  by  paying  strict  atten- 
tion to  asepsis,  phalanges  or  finger  tips  which  have  been  entirely 
severed  may  be  sutured  in  place  and  caused  to  reunite.  Careful  sub- 
cutaneous suturing  of  the  periosteum  with  catgut  and  absolute  immo- 


§104]  ACUTE  INFLAMMATIONS   OF  BONE.  633 

bilisation  of  the  affected  part  are  of  chief  importance.  I  once  saw 
a  terminal  phalanx  which  had  reunited  in  this  way  come  off  again 
four  weeks  later  in  consequence  of  a  violent  blow,  and  then  it  could 
not  be  made  to  heal  on  a  second  time.  If  a  piece  has  been  taken 
out  of  the  continuity  of  a  bone  by  a  sabre  cut,  for  example,  and  there 
is  no  periosteum  left  at  the  spot  in  question,  the  bone  ^vill  granu- 
late very  soon,  and  skin  will  gradually  form  over  the  granulating 
surface.  Yery  often  the  loss  of  substance  in  a  bone  of  the  skull  is 
not  completely  replaced  by  new  bone,  and  persists  as  a  more  or  less 
appreciable  gap. 

The  repair  of  a  wound  in  bone  is  essentially  the  same  as  that  which 
takes  place  in  fractures,  and  is  described  on  page  602.  Gunshot  wounds 
of  bone  and  soft  parts  will  be  discussed  in  conjunction  with  injuries  of 
joints  (see  §  124:). 

§  103.  The  Inflammations  of  Bone. — The  inflammations  of  bone  gen- 
erally begin  in  the  periosteum  and  in  the  medulla  in  the  form  of  a 
periostitis  and  osteomyelitis.  From  these  regions  the  inflammation 
extends  to  the  bone  substance  proper  and  to  the  epiphyseal  or  articular 
cartilages,  giving  rise  to  a  true  ostitis  or  chondritis.  The  ostitis  mani- 
fests itself  either  as  an  absorption  of  bone  (rarefying  ostitis)  or  as  a  new 
formation  of  bone  (condensing  ostitis).  The  inflammatory  changes  in 
the  bone  proper  take  place  in  the  parts  surrounding  the  vessels  and  in 
the  medullary  spaces.  The  pathological  absorption  of  bone  is,  as  a  rule, 
analogous  to  the  normal  absorption — i.  e.,  it  takes  place  in  the  form  of 
pit-like  depressions,  the  so-called  Howship's  lacunae  (lacunar  absorption 
of  bone),  which  are  hollowed  out  of  the  bone  by  the  action  of  polynu- 
clear  cells — the  osteoclasts,  as  they  are  called  (Kolliker,  Fig.  101).  In 
this  lacunar  absorption  of  bone  the  lime  salts  and  the  ground  substance 
are  always  dissolved  more  or  less  simultaneously.  In  a  second  form  of 
absorption  of  bone — in  halisteresis  ossium — the  lime  salts  become  at 
first  dissolved,  the  decalcified  ground  substance  of  the  bone  persisting 
for  some  time  longer.  The  latter  kind  of  absorption  of  bone  takes 
place  especially  in  osteomalacia  (see  §  109).  The  changes  which  occur 
in  inflammation  of  cartilage  consist  mainly  in  a  proliferation  of  the  car- 
tilage cells  and  in  a  fibrillary  degeneration  and  necrosis  of  the  ground 
substance  of  the  cartilage. 

§  101.  Acute  Inflammations  of  Bone,  Acute  Periostitis,  and  Acute 
Osteomyelitis. — The  acute  inflammations  of  bone,  in  the  form  of  an 
acute  inflammation  of  the  periosteum  and  medulla  (acute  periostitis 
and  acute  osteomyelitis),  have  been  studied  in  their  simplest  form  in 
§  101,  under  the  subject  of  Callus  Formation  after  subcutaneous  frac- 
tures.    In  every  instance  where  a  suppurative  periostitis  and  osteo- 


^34  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

myelitis  occurs  it  is  due,  like  any  acute  suppuration,  to  infection  by 
niicro-oroanisnis.  The  infection  lias  either  taken  place  at  the  point 
where  the  injury  was  received,  as  in  the  case  of  compound  fractures 
which  are  not  treated  antiseptically  and  open  wounds  of  the  perios- 
teum, or  it  has  spread  from  a  suppurative  inflammation  of  the  sur- 
rounding parts,  or,  thirdly,  it  originates  by  infectious  matter  being 
brought  from  another  portion  of  the  body  by  the  blood-vessels  and 
deposited  in  the  bone  (hsematogenous  infection).  The  latter  kind 
inchides  the  metastatic  inflammations  of  the  periosteum  and  medulla 
occ.irriug  in  pysemia,  typhoid,  and  scarlet  fevers,  etc.  Such  acute  in- 
flammations of  the  periosteum  and  medulla  not  only  develop  in  the 
course  of  acute  infectious  diseases  from  metastasis  of  their  poisons,  but 
also  occur  in  perfectly  healthy  individuals,  and  are  due  to  micro-organ- 
isms which  are  carried  to  the  bone  in  the  blood  from  the  external  cuta- 
neous covering,  the  intestinal  tract,  the  lungs,  etc.,  and  there  excite  the 
various  kinds  of  inflammation. 

Acute  Infectious  Osteomyelitis. — The  severest  acute  inflammation  of 
bone  is  the  primary  acute  infectious  osteomyelitis  and  periostitis  (Liicke) 
first  described  by  Chassaignac  as  osteomyelite  sj>ontanee  diffuse  des  os 
or  tyjyhus  des  os  or  des  memhres.  This  is  chiefly  observed  in  young 
people.  Young  growing  bones,  as  a  general  thing,  possess  a  more  or 
less  pronounced  tendency  towards  inflammatory  processes.  An  active 
development  of  new  vessels  takes  place  in  growing  bone,  and  the  ter- 
minal loops  of  the  vessels  with  their  dilatations  lie  close  to  the  epiphys- 
eal cartilage  ;  consequently  solid  impurities,  especially  micro-organ- 
isms, can  be  deposited  in  the  cartilage  from  the  retarded  blood  stream. 
Moreover,  the  filtration  and  deposition  of  micro-organisms  and  all  solid 
impurities  contained  in  the  blood  are  rendered  easy  in  the  medulla  of 
every  bone,  for  the  reason  that  the  blood  stream  is  not  confined  by  walls 
as  it  passes  through  the  sacculated  medullar}^  spaces.  Osteomyelitis 
occurs  most  commonly  in  the  femur  of  young  subjects,  possibly  because 
this  bone  grows  the  most  rapidly.  According  to  Haaga's  statistics, 
covering  foi'ty  years'  experience  in  the  clinic  at  Tiibingen,  the  disease 
occurs  more  frequently  in  men  than  in  women,  the  proportion  being 
3.38  to  1.  Acute  infectious  osteomyelitis  is  particularly  common  in 
certain  regions,  such  as  Switzerland,  the  mountainous  parts  of  South 
Germany,  and  the  coast  of  North  Germany.  Epidemics  of  very  severe 
cases  occur  in  these  places.  In  other  instances  acute  osteomyelitis  is 
secondary,  and  occurs,  for  example,  in  the  course  of  acute  infectious 
diseases,  such  as  measles,  scarlet  fever,  small-pox,  or  typhoid  fever  (see 
page  641).  "We  shall  confine  ourselves  at  present  mainly  to  the  pri- 
mary acute  osteomyelitis. 


§  104.]  ACUTE  mFLAMMATIONS  OF  BONE.  635 

Etiology  of  Primary  Acute  Osteomyelitis.— Our  knowledge  of  the  etiology 
of  primary  acute  infectious  osteomyelitis  has  recently  been  advanced.,  par- 
ticularly by  Kocher,  Rosenbach,  Kraske,  and  others.  It  has  been  found  that 
in  the  majority  of  cases  it  is  caused  by  the  yellow  pus  coccus,  the  Staphylo- 
coccus pyogenes  aureus,  less  often  by  the  Staphylococcus  p>yogenes  albus 
eitreus,  or  the  Streptococcus  pyogenes  (see  pages  327-331).  Occasionally 
there  is  a  mixed  infection  by  various  pus  cocci.  In  fifteen  cases  of  acute 
osteomyelitis  Rosenbach  found  the  Staphylococcus  pyogenes  aureus  four- 
teen times,  once  with  the  chain  coccus  of  cellulitis,  and  once  with  the  white 
pus  coccus  {Staphylococcus  pyogenes  albus).  Out  of  ninety  cases  of  osteo- 
myelitis Lannelongtie  found  staphylococci  in  seventy  (fifty-six  times  the 
Staphylococcus  aureus),  streptococci  in  only  ten.  pneumococci  in  three,  and 
Eberth  s  bacilli  in  four  ;  the  streptococci  and  pneumococci  were  found  chiefly 
in  young  children  from  one  to  five  years  of  age.  The  Stap)hylococcus  py- 
ogenes aureus  is  more  virulent  than  the  Staphylococcus  albus,  and  in  case 
of  streptococcus  infection  death  is  likely  to  occur  promptly  from  sepsis. 
In  some  localities  the  disease  is  produced  chiefly  by  the  Staphylococcus 
albus.  Osteomyelitis  may  also  be  caused  by  the  typhoid  bacillus,  Frankel's 
diplococcus,  the  Micrococcus  pyogenes  tenuis,  the  Micrococcus  tetragenus, 
the  Bacillus  pyocyaneus,  the  Bacillus  pyogenes  foetidus,  and  the  Bac- 
terium coli  commune,  as  well  as  by  the  intravenous  injection  of  the 
bacterium  that  produces  lactic  acid.  Like  any  other  acute  inflammation 
and  suppuration,  osteomyelitis  can  be  excited  experimentally  in  animals 
by  agents  having  a  purely  chemical  action,  such  as  turpentine  or  sterilised 
cultures,  the  latter  producing  their  effect  through  the  chemical  products 
resulting  from  the  metabolism  of  the  pus  cocci  (Ullmann).  In  short, 
osteomyelitis  can  be  excited  by  many  varieties  of  micro-organisms  and 
chemical  agents,  but  the  ordinary  pus  cocci  are  the  most  common  cause 
of  the  disease.  Consequently  osteomyelitis  is  not  due  to  a  specific  poison, 
as  was  believed  to  be  the  case  for  a  long  time,  but  it  may  be  caused  by 
any  kind  of  micro-organism  which  excites  acute  inflammation  and  sup- 
puration. Acute  infectious  osteomyelitis  is  essentially  a  phlegmon,  so  to 
speak,  of  the  medullary  cavity.  By  transferring  osteomyelitic  pus,  or  the 
above-mentioned  micro-organisms,  to  the  soft  parts,  cellulitis  with  suppura- 
tion is  produced.  The  experiments  of  Becker  and  others  show  that  after 
the  introduction  of  pus  cocci  into  the  circulatory  system  or  peritoneal 
cavity,  typical  acute  osteomyelitis  is  particularly  likely  to  develop  if  the 
affected  bones  have  been  previously  contused  or  broken,  for  the  reason 
that  broken  or  contused  bone  offers  a  favourable  medium  for  the  growth  of 
the  pus  cocci.  Lexer,  Canon,  and  others  caused  osteomyelitis  in  young  grow- 
ing rabbits  by  injecting  the  Staphylococcus  pyogenes  aureus  into  the  jugular 
vein  without  injuring  the  bone  ;  in  fully  grown  animals  the  injection  of  the 
same  caused  inflammations  of  the  muscles,  joints,  and  internal  organs  simi- 
lar to  pyaemia.  Jordan,  Mliller,  and  Sonnenburg  regard  osteomyelitis  as 
mainly  a  pyaemia  with  localisation  in  the  bone,  and  occurring  chiefly  in  the 
growing  period. 

The  origin  of  acute  infectious  osteomyelitis  is  to  be  explained  on  the  sup- 
position that  the  above-mentioned  micro-organisms  enter  the  circulation  from 
some  point  in  the  skin,  or  in  the  lungs  or  intestinal  tract,  for  example,  par- 


636  INJURIES  AND  SURGICAL   DISEASES  OF   BONE. 

ticularly  Tvhen  at  this  point  there  is  an  inflammation,  such  as  a  furuncle, 
or  even  a  slight  interruption  of  continuity,  and  are  carried  off  in  the  blood, 
from  which  they  are  deposited  in  the  medullary  portion  of  the  bones  of 
youthful  subjects  for  the  anatomical  reasons  mentioned  before;  here  they 
develop,  and  give  rise  to  severe  suppurative  or  gangrenous  inflammation 
with  secondary  involvement  of  the  bone,  periosteum,  and  frequently  the 
joints.  Colzi's  experiments  seem  to  show  that  the  bacteria  in  osteomyelitis 
enter  the  body  most  frequently  from  the  skin,  less  often  from  the  lungs  or 
intestinal  tract.  Osteomyelitis  may  result  from  any  acute  pus  focus  in  any 
oro-an  of  the  body  in  case  the  pus  cocci  are  carried  to  the  medulla  of  a  bone. 
As  we  remarked  before,  traumatic  lesions  of  bone  favour  the  development 
of  acute  infectious  osteomyelitis.  How  far  catching  cold  conduces  to  its 
occurrence  is  a  matter  which  cannot  be  determined,  but  the  majority  of  sur- 
o-eons  believe  that  it  exerts  some  influence.  Acute  osteomyelitis  is  either 
localised  in  one  bone  or  in  several  at  the  same  time,  starting  from  one  focus. 
In  other  cases  the  osteomyelitis  located  in  one  bone  leads  to  metastatic  osteo- 
myelitis of  other  bones.  Furthermore,  acute  osteomyelitis  is  either  a  primary 
disease  or  results  secondarily  from  some  infectious  focus — e.  g.,  a  furuncle, 
suppurative  inflammation  of  various  organs  or  in  connection  with  an  acute 
infectious  disease  (measles,  scarlet  fever,  typhoid,  diphtheria,  pya?mia,  septi- 
caemia, etc.). 

Anatomical  Changes  in  Acute  Infectious  Osteomyelitis.— The  anatomical 
changes  in  acute  infectious  osteomyelitis  vary  with  the  species  of  bacteria 
which  causes  the  inflammation.  Generally  speaking,  osteomyelitis  produced 
by  staphylococci  causes  marked  local  destruction  of  the  bone ;  that  due  to 
streptococci  often  results  in  inflammation  of  joints,  and  fatal  general  infec- 
tion frequently  follows  before  extensive  suppuration  has  occurred  in  the 
bone.  Osteomyelitis  produced  by  typhoid  bacilli  does  not  run  so  acute  a 
course  as  the  usual  kinds ;  the  suppuration  acts  more  like  a  cold  abscess, 
and  ulcerative  and  fungous  forms  often  occur.  The  anatomical  changes  are 
in  the  main  the  following :  At  the  outset  there  is  a  diflpuse  hyperaemia  of  the 
medulla,  and,  later,  yellowish  or  greyish  coloured  foci  of  suppuration  appear 
in  it  which  not  infi'equently  coalesce  and  form  a  single  large  collection  of 
pus.  In  the  severest  cases  there  is  observed  a  general  suppuration  of  the 
medulla  of  the  entire  diajihysis — most  commonly  of  the  femur  or  tibia — with 
secondary  collections  of  pus  in  the  Haversian  canals,  between  the  perios- 
teum and  bone,  in  the  periosteum,  and  in  the  adjoining  soft  parts.  The 
periosteum  j)robably  becomes  involved  for  the  most  jjart  secondarily,  and 
is  the  seat  of  inflammatory  inflltration  and  swelling  (serous,  sei"ofibrinoi;s 
periostitis)  or  of  suppuration.  As  a  rule,  the  jdus  in  acute  infectious  osteo- 
myelitis is  rich,  in  fat,  in  consequence  of  the  acute  degeneration  of  the  me- 
dullary cells.  The  suppurative  separation  of  the  epiphyses  at  their  junction 
with  the  diaphyses  is  a  pathological  change  of  considerable  importance,  as 
well  as  the  secondary  development  of  inflammations  of  the  neighbouring 
joints  either  in  the  form  of  a  transitory  mild  sei^ous  or  sero-fibrinous  inflam- 
mation, or  of  a  severe  suppurative  arthritis.  Haaga  states  that  in  four  hun- 
dred and  seventy  cases,  permanent,  slight,  or  pronounced  changes  remained 
in  the  joints  one  hundred  and  eighty-nine  times.  Curvatures  or  angular 
deformities  of  bones  sometimes  develop  after  osteomyelitis  (see  page  638). 


§  104.]  ACUTE  INFLAMMATIONS   OF   BONE.  63Y 

Necrosis  of  the  bone  involved  is  a  very  frequent  accompaniment  of  the 
inflammatory  process,  and  varies  in  amount  up  to  necrosis  of  the  entire  shaft 
of  a  long  bone.  In  the  mildest  cases  suppuration  and  necrosis  do  not  occur, 
but  there  is  only  a  condensing  ostitis.  The  forms  described  as  ostitis  and 
periostitis  are  mainly  the  result  of  a  mild  non-suppurative  osteomyelitis  (see 
also  pages  633  and  641).  Acute  infectious  osteomyelitis  terminates  either  in  a 
complete  restitutio  ad  integrimi,  with  or  without  suppuration,  or  in  a  vary- 
ing amount  of  necrosis  of  the  bone,  or  in  death,  particularly  from  pyasmia  and 
septicaemia.  Pyasmia  and  septicaemia  are  both  the  cause  and  result  of  acute 
osteomyelitis — i.  e.,  the  latter  either  causes  sepsis  by  the  bacteria  and  their 
products  being  carried  into  the  blood,  or  it  is  a  secondary  metastatic  inflam- 
mation resulting  from  an  already  existing  sepsis.  Not  infrequently  encap- 
sulated central  bone  abscesses  are  left  behind  which  persist  for  years. 

Osteomyelitis  occurs  either  in  a  single  bone,  involving  most  commonly 
the  diaphysis  of  the  long  hollow  bones  (femur,  tibia),  or  as  a  multiple  affection 
in  different  bones.  In  the  latter  instance  there  is  a  simultaneous  infection  of 
several  bones,  or  the  primary  disease  in  one  bone  gives  rise  to  metastases  in 
other  bones ;  the  latter  is  by  far  most  frequently  the  case.  The  short,  flat 
bones  most  commonly  affected  are  the  clavicle,  the  ileum,  and  the  scapula. 
After  total  necrosis  of  the  clavicle  the  bone  may  be  completely  regenerated, 
its  shape  restored,  and  the  function  of  the  arm  undisturbed. 

Clinical  Course  of  Acute  Infectious  Osteomyelitis. — The  clinical  course 
of  acute  infectious  osteomyelitis  varies  greatly.  The  worst  cases  pre- 
sent the  symptoms  of  a  very  severe  constitutional  disease,  with  high 
fever,  delirium,  rapid  swelling  of  the  affected  bone,  and  death  within 
a  few  days.  In  the  mildest  cases  the  local  and  constitutional  manifes- 
tations are  slight.  The  cases  of  moderate  severity  are  probably  the 
most  common.  The  amount  of  constitutional  infection  does  not  always 
correspond  to  the  extent  of  the  local  disease.  The  fever  in  the  severe 
cases  is,  as  a  rule,  very  high,  reaching  41°  C.  (104.1°  F.).  The  disease 
generally  begins  with  a  chill  two  to  three  days  after  a  traumatism,  for 
example,  or  exposure  to  cold,  and  during  the  days  immediately  follow- 
ing the  local  disease  can  usually  be  readily  made  out  in  one  bone,  less 
often  in  several  bones.  The  intense  pain,  the  even  swelling,  the  absence 
at  first  of  any  fluctuation  or  inflammation  of  the  soft  parts,  and  the 
pronounced  disturbance  of  function  are  in  general  characteristic  of  the 
local  disease  of  the  bone.  Many  cases  do  not  begin  so  acutely ;  on  the 
contrary,  they  often  commence  very  gradually.  Occasionally  the  dis- 
ease runs  a  course  which  presents  the  picture  of  an  acute  articular  rheu- 
matism with  inflammation  of  the  large  joints.  In  these  cases  the 
osteomyelitis  is  always  multiple,  and  the  inflammation  of  the  joints 
(secondary  to  disease  of  the  neighbouring  epiphyses)  often  goes  on  to 
suppuration. 

The  subsequent  course  of  acute  infectious  osteomyelitis  is  in  the 
majority  of  instances  favourable.     In  the  mildest  cases  complete  resti- 


638  IXJURIES  AND   SURGICAL   DISEASES  OF  BONE. 

tutlo  ad  integrum  takes  place  iu  two  to  three  to  four  weeks  without 
any  noticeable  suppuration.  In  the  severest  cases  the  suppuration  of 
the  metlulla  runs  a  very  rapid  course,  accompanied  by  secondary  sup- 
puration of  the  periosteum  and  phlegmonous  sloughing  of  the  soft 
parts,  sometimes  with  the  evolution  of  gas.  Death  in  such  cases  gen- 
erally occurs  from  what  looks  like  septicaemia  with  severe  typhoid 
symptoms,  or  from  pysemia  with  secondary  abscesses  in  the  internal 
organs.  Probably  the  most  common  termination  is  recovery,  with 
necrosis  corresponding  to  the  amount  of  bone  which  has  been  affected. 
The  necrosis  is  sometimes  central  and  sometimes  peripheral — i.  e.,  it  is 
confined  to  the  bone  adjoining  the  medulla  or  the  periosteum.  If 
there  is  extensive  suppuration  in  the  medulla  and  periosteum  the  entire 
diaphysis  of  a  long  bone  may  die.  Not  infrequently  circumscribed 
collections  of  pus  in  the  medullary  cavity  become  encapsulated  and 
form  abscesses  running  a  chronic  course  without  necrosis,  and  leading 
to  a  characteristic  diffuse  enlargement  of  the  affected  bone.  The  sup- 
purative separation  of  the  epiphyses  is  another  complication  occurring 
in  young  subjects  when  the  suppuration  invades  these  parts.  The 
epiphyseal  separation,  as  in  fractures  or  traumatic  separations,  is 
recognised  by  the  abnormal  mobility.  Usually  there  is  only  separa- 
tion of  one  epiphysis,  which  in  the  femur,  for  example,  is  the  lower; 
only  in  rare  instances  are  both  involved.  The  separation  of  both 
epiphyses  of  a  single  bone  appears  to  have  occurred  most  commonly 
in  the  tibia. 

The  secondary  inflammations  of  the  joints  which  accompany  acute 
infectious  osteomyelitis  are  either  acute  or  subacute  serous  inflamma- 
tions, or  severe  suppurative  forms,  which  may  even  be  attended  by 
the  evolution  of  gas. 

Sometimes,  after  an  acute  osteomyelitis  has  run  its  course,  even 
when  no  extensive  necrosis  has  taken  place,  the  bone  may  be  left 
abnormally  soft.  It  may  lose  its  strength  to  such  an  extent  that  curva- 
ture, angular  defonuity,  or  axial  rotation  of  the  diaphysis  of  a  bone, 
like  the  femur,  may  be  produced  by  muscular  action  and  by  the  super- 
imposed weight  of  the  1)ody  (Stahl,  Oberst,  and  others).  In  such 
cases  of  curvature  or  deformity  the  bones  involved  are  remarkably 
porous,  and  at  the  point  where  the  disease  is  located  a  fistula  will 
generally  be  found  which  leads  to  a  focus  of  rarefied  bone  vdih.  a 
sequestrum. 

As  Krause  has  correctly  stated,  the  osteomyelitic  cocci  appear  to 
possess  great  powers  of  resistance,  since  renewed  fonnation  of  pus 
has  been  observed  in  old  osteomyelitic  areas  even  after  the  lapse  of 
years.     This   is   the   explanation  for  those   cases  of   multiple   osteo- 


§104.]  ACUTE  INFLAMMATIONS   OF  BONE.  639 

myelitis  in  which  the  foci  of  the  process  have  apparently  completely 
disappeared,  but  in  which,  nevertheless,  suppuration  and  necrosis  sub- 
sequently develop. 

Diagnosis  and  Prognosis  of  Acute  Osteomyelitis.— The  diagnosis  of  acute 
infectious  osteomyelitis  can  be  made  from  what  has  been  stated  about  the 
anatomical  changes  and  the  symptomatology. 

The  prognosis,  in  the  majority  of  cases,  is  favourable  quoad  vitam.  But 
it  must  be  borne  in  mind  that  the  disease  may  cause  death  at  any  stage,  so 
long  as  an  escape  is  not  provided  for  the  pus  by  chiselling  open  the  medul- 
lary cavity.  Many  cases,  especially  those  caused  by  the  streptococcus,  run  a 
rapidly  fatal  course.  After  the  suppuration  has  subsided,  it  is  mainly  the 
extent  of  the  necrosis,  the  amount  of  inflammation  which  has  occurred  in 
the  joints,  the  condition  of  the  epiphyses,  etc.,  which  determine  the  character 
of  the  case. 

The  Treatment  of  Acute  Infectious  Osteomyelitis. — The  treatment  of 
acute  primary  osteomyelitis  has  gained  in  efficacy  with  our  knowledge 
of  the  etiology  of  the  disease.  In  the  treatment,  a  distinction  must  be 
made  between  the  severe  cases,  which  run  a  very  acute  course,  and 
those  which  are  mild  and  subacute.  In  the  severest  cases  with  high 
fever,  a  means  of  escape  should  be  provided  for  the  pus  as  soon  as 
possible  by  making  one  or  more  openings  into  the  bone — e.  g.,  with  a 
dentist's  drill  or  an  electro-motor  apparatus  (see  page  90),  and  in  case 
pus  is  found  the  medullary  cavity  is  opened  sufficiently  in  the  form  of 
a  gutter  with  chisel  and  mallet.  If  operative  measures  are  adopted 
early  enough,  the  otherwise  unavoidable  necrosis  of  the  bone  and  the 
breaking  through  of  pus  into  a  neighbouring  joint  may  sometimes  be 
prevented,  and  the  course  of  the  disease  will  thus  be  rendered  milder 
and  shorter  than  it  otherwise  would  be.  To  avoid  recurrences  and  to 
obtain  speedy  recovery,  it  will  often  be  found  a  better  plan,  instead  of 
making  a  gutter-shaped  opening  into  the  medullary  cavity  of  a  long, 
hollow  bone,  to  remove  all  of  the  bone  except  a  wall  of  cortex.  This 
early  scraping  out  of  the  infected  medulla  has  recently  been  energetic- 
ally supported  by  Tscherning  (Copenhagen),  Thelen,  and  others,  and  is 
in  every  respect  a  rational  procedure,  when  it  is  remembered  that  we 
have  to  deal  essentially  with  a  cellulitis  of  the  medulla ;  and  in  the 
case  of  any  cellulitis  it  should  be  our  aim  to  evacuate  the  pus  at  the 
earliest  possible  moment.  It  is  not  always  easy  to  decide  in  what  cases 
the  aseptic  opening  of  the  diseased  bone  with  the  chisel  should  be 
attempted  ;  moreover,  many  cases  run  such  a  rapidly  fatal  course  that 
the  correct  diagnosis  cannot  be  made  at  an  early  enough  period.  The 
evacuation  of  pus  from  bones,  such  as  those  of  the  pelvis,  is  difficult, 
and  I  have  seen  very  severe  cases  involving  just  these  bones  where 
death  occurred  quickly.      After  opening  the  medullary  cavity  of   a 


640  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

lono;  hollow  bone,  the  suppurative  focus  should  be  scraped  out,  and, 
if  necessary,  the  entire  medullary  cavity.  The  periosteum  and  soft 
parts  should  likewise  be  carefully  examined  for  the  presence  of  pus, 
and,  if  found,  it  should  be  let  out  by  incision  and  drainage.  Finally, 
the  medullary  cavity  should  be  disinfected  as  carefully  as  i)ossible  with 
a  one-tenth-per-cent.  solution  of  bichloride  of  mercury  or  a  three-per- 
cent, solution  of  carbolic  acid,  and  then  filled  with  iodofoi-m  gauze, 
over  which  is  placed  an  antiseptic  protective  dressing.  Instead  of  a 
dry  aseptic  dressing,  wet  dressings  of  one  to  two  per  cent,  alumin- 
ium acetate  may  be  employed  to  advantage.  Immobilisation  of  the 
extremity  in  the  best  possible  position  by  splints,  etc.,  cannot  be 
emphasised  too  strongly.  Unfortunately,  in  spite  of  energetic  and 
early  operative  local  treatment,  some  of  the  severe  cases  will  die  in 
consequence  of  the  systemic  intoxication  already  present,  which  even 
an  amputation  or  a  total  subperiosteal  resection  of  the  diseased  bone 
will  not  always  prevent.  Complete  resection  of  the  bone — i.  e.,  the 
removal  of  the  diseased  bone  in  toto — seems  to  me  very  inadvisable, 
as  its  efficacy  has  as  yet  not  been  sufficiently  established.  Amputa- 
tion in  the  acute  stage  is  rarely  indicated,  though  it  may  be  in  the 
later  stages,  when  suppuration  becomes  so  excessive  as  to  threaten  to 
carry  off  the  patient  from  exhaustion. 

In  the  moderately  severe  and  the  mild  cases  the  local  treatment 
consists  in  the  energetic  application  of  ice,  in  placing  the  extremity 
in  an  elevated  position,  and  in  immobilising  it  as  much  as  possible 
with  a  splint.  Others  prefer  moist  heat  to  ice  for  alleviating  the  pain. 
I  consider  that  the  application  of  iodine,  which  was  formerly  so  much 
used,  has  but  little  effect.  If  there  is  marked  swelling  of  the  perios- 
teum and  the  pain  due  to  this  is  severe,  even  though  no  pus  can  be 
obtained  by  a  test  puncture,  I  nevertheless  advocate  early  incisions  to 
lessen  the  tension,  and  thus  ease  the  patient's  pain.  Furthermore,  it 
is  possible  by  this  means  to  prevent,  or  at  any  rate  to  limit,  a  subse- 
quent necrosis  of  the  bone.  Not  infrequently  cases  which  were  at  the 
outset  mild,  become  so  severe  that  it  may  be  necessary  to  chisel  a 
groove  into  the  medullary  cavity  and  drain  or  pack  the  latter  with 
iodoform  gauze. 

As  regards  the  treatment  of  complications  the  following  should  be 
noted :  Inflammations  of  joints  are  treated  according  to  the  general 
principles  applicable  to  these  affections  (see  Diseases  of  Joints).  If 
suppuration  occurs,  the  joint  should  be  opened  and  drained  as  soon  as 
possible.  Separation  of  the  epiphysis  is  treated  in  the  same  way  as 
a  fracture.  Curvatures  of  bone  following  osteomyelitis  can  sometimes 
be  overcome,  after  scraping  out  the  osteomyelitic  focus  and  removing 


§  104.]  ACUTE  INFLAMMATIONS  OP  BONE.  641 

the  sequestrum  which  may  be  present,  by  extension  with  a  heavy 
weight  (five  to  ten  kilogrammes).  The  treatment  of  the  necrosis 
which  is  so  common  a  result  of  osteomyelitis  is  described  in  §  106. 
Defects  in  bone  are  repaired  by  one  of  the  methods  described  on  pages 
607  and  610. 

Amputation  accompanied  by  Scraping  out  the  Bone  Stump.— Perkowsky 
practised  aixix^utation  in  eight  severe  cases  of  osteomyelitis,  and  then  scraped 
out  the  medullary  cavity  of  the  diseased  bone  stump,  removing  in  three  cases 
the  medulla  of  the  entire  stump  with  the  sharp  spoon,  so  that  only  a  thin 
shell  of  bone  was  left.  Necrosis  did  not  take  place  in  a  single  case,  and  a 
rapid  recovery  followed  in  all  eight  cases  under  iodoform  dressings.  Per- 
kowsky thus  avoided  disarticulation  or  amputation  of  the  limb  at  a  higher 
point. 

The  treatment  of  acute  periostitis  occurring  by  itself  is  conducted 
according  to  the  genei-al  rules  which  apply  to  inflammation.  If  the 
acute  periostitis  is  suppurative,  incision  is  employed ;  if  not  suppura- 
tive, antiphlogesis. 

The  Acute  Traumatic  Inflammations  of  the  Periosteum  and  Medulla. — 
Acute  traumatic  inflammations  of  the  periosteum  and  medulla  are  ob- 
served after  injuries  of  various  kinds,  such  as  contusions,  wounds  of  the 
periosteum,  subcutaneous  and  compound  fractures,  wounds  of  bone,  etc. 
Acute  non-suppurative  periostitis  and  osteomyelitis  take  place  after 
every  contusion  and  subcutaneous  fracture.  A  typical  non-suppura- 
tive periostitis  occurs  not  infrequently  in  recruits  in  consequence  of 
their  drilling  exercises ;  the  excessive  contraction  of  the  fascia  and  the 
muscles  of  the  leg  causes  localised  thickenings  of  the  bone,  particularly 
in  the  front  of  the  tibia  (Laveran,  Laub).  The  suppurative  form  is 
always  caused  by  infection  with  bacteria  which  enter  through  some 
wound  or  circulate  in  the  blood.  This  includes,  moreover,  the  acute 
osteomyelitis  of  the  amputation  stump,  which,  especially  in  the  days  be- 
fore antisepsis,  terminated  in  death  from  pyaemia.  At  present  we  have 
learned  to  avoid  this  form  of  osteomyelitis  with  certainty  in  our  amputa- 
tions by  employing  antisepsis  and  asepsis.  The  anatomical  changes  and 
the  cause  of  the  acute  (traumatic)  periostitis  and  osteomyelitis  are  essen- 
tially the  same  as  in  the  above-described  spontaneous  acute  infectious 
osteomyelitis  and  periostitis. 

Metastatic  Inflammations  of  Bone. — The  metastatic  inflammations  of 
bone  in  pygemia,  typhoid  and  scarlet  fevers,  measles,  small-pox,  etc., 
are  either  analogous  to  the  spontaneous  acute  infectious  osteomyelitis 
and  periostitis,  or  they  run  a  chronic  course  with  the  formation  of  cir- 
cumscribed cold  abscesses.  The  osteomyelitis  following  scarlet  fever 
is  rather  common  (Chiari,  Mallory).  The  inflammations  of  bone  in  the 
44 


6-t2  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

course  of  typhoid  fever  usually  occur  during  convalescence,  are  single  or 
multiple,  and  are  situated  in  the  shaft  of  long  bones  and  also  in  the 
ribs.  They  begin  with  rheumatic  pains  and  nm  their  course  with 
fever.  The  abscesses  have  been  found  to  contain  pus  cocci,  virulent 
typhoid  bacilli — even  years  after  recovery  from  the  typhoid — Bacteriiwv 
coli  commune,  and  other  micro-organisms.  These  bacteria  were  found 
in  some  cases  in  combination,  and  in  other  cases  each  kind  was  found  by 
itself.  The  bacteriological  examination  proved  in  some  instances  neg- 
ative. In  the  cases  of  metastatic  bone  inflammation  from  plugging 
of  the  vessels  by  emboli,  a  corresponding  necrosis  of  bone  occurs  which 
is  called  an  ''  embolic  necrosis.''  Such  embolic  necroses  from  obstruc- 
tion to  the  afferent  flow  of  blood  are  occasionally  observed  in  endocar- 
ditic  processes,  when  blood-clots  with  or  without  micro-organisms  break 
loose  from  the  growths  on  the  endocardium  and  are  swept  away  and 
lodge  in  the  bones.  Epiphyseal  separations  and  secondary  joint  diseases, 
which  were  described  above,  may  also  accompany  metastatic  periostitis 
and  osteomyelitis. 

Growth  Fever  and  Growth  Pain. — In  young  subjects  there  is  occasionally 
observed  a  marked  temporary  tenderness  to  pressure  in  the  epiphyses  of  the 
long  bones,  especially  the  femur,  humerus,  and  tibia,  accompanied  by  inflam- 
matory irritation  of  the  neighbouring  joints,  with  the  manifestations  of  fever 
and  a  corresponding  disturbance  of  the  general  health.  Bouilly  and  Juillier 
have  designated  this  condition  as  growth  fever  or  growth  pain.  In  most  of 
these  cases  there  is  probably  a  real  disease  of  the  bones  or  joints  ;  the  children 
have  pain  because  they  are  ill,  and  not  because  they  are  growing.  The  chil- 
dren in  question  show  an  excessive  growth.  Not  infrequently  rhachitis  is 
present.     Pure  growth  pains  with  fever  are,  in  my  opinion,  extremely  rare. 

Embolic  Foreign-Body  Inflammations  of  Bone. — Great  interest  attaches 
to  the  embolic  foreign-body  inflammations  of  bone  which  are  observed 
in  mother-of-pearl  turners  and  workers  in  woollen  and  jute  mills.  Peo- 
ple employed  in  these  occupations  breathe  in  the  particles  of  mother- 
of-pearl  dust,  wool,  or  jute,  which  then  pass  from  the  lungs  into  the 
circulation  and  lodge  in  the  small  arteries  of  the  medullary  portion  of 
the  bones,  particularly  the  terminal  arteries  at  the  extremities  of  the 
diaphysis,  and  here  excite  embolic  inflammation  of  the  medulla  with 
secondary  involvement  of  the  periosteum.  As  is  the  case  with  acute 
infectious  osteomyelitis  and  periostitis,  youthful  individuals  are  the 
ones  who  are  principally  affected  by  these  inflammations  of  the  me- 
dulla in  the  diaphyseal  ends  of  the  bones  and  in  the  epiphyses. 
Gussenbaur,  Englisch,  and  Levy  have  given  accurate  descriptions  of 
the  inflammations  of  bone  to  which  mother-of-pearl  turners  are  sub- 
ject. The  symptoms  consist  in  very  painful  swellings,  which  usually 
appear  suddenly  at  the  ends  of  the  diaphyses  with  marked  swelling  of 


§  105.]  THE   CHRONIC  INFLAMMATIONS   OF   BONE.'  643 

the  periosteum.  The  course  of  the  affection  is  generally  subacute,  and 
suppuration  has  as  yet  never  been  observed.  Restitutio  ad  integmm 
ordinarily  follows,  the  worst  that  happens  being  a  thickening  of  the 
periosteum,  which  persists  for  a  greater  or  less  length  of  time.  But  if 
the  turners  resume  their  occupation,  recurrences  of  the  inflammation 
are  frequently  observed,  which  run  a  chronic  course,  with  thickening 
of  the  spongy  bones  of  the  carpus  or  tarsus,  or  of  the  diaphyseal  ends 
of  the  long  bones. 

Klein  has  described  the  bone  disease  of  jute  spinners.  In  this,  too, 
there  is  an  inflammation  of  the  medulla  and  periosteum  in  the  region 
of  the  epiphyseal  cartilages,  accompanied  by  severe  pain.  A  consid- 
erable growth  of  epiphyseal  cartilage  usually  takes  place,  giving  rise  to 
secondary  curvature  of  the  bones,  particularly  the  tibia.  In  this  affec- 
tion also  suppuration  or  necrosis  never  occurs. 

§  105.  The  Chronic  Inflammations  of  Bone  {Chronic  Periostitis^  Os- 
titis, and  Osteomyelitis). — The  most  important  chronic  diseases  of  bone 
are  the  mycotic,  of  which  the  tubercular,  syphilitic,  and  actinomycotic 
inflammations  of  bone  are  prominent  examples.  Furthermore,  acute 
infectious  diseases,  such  as  measles,  scarlatina,  typhoid  fever,  etc.,  may 
be  followed  not  only  by  acute  inflammations  of  bone,  as  mentioned 
above,  but  also  by  inflammations  which  are  at  first  latent,  and  then 
subsequently  manifest  themselves  as  affections  running  a  chronic  course. 
The  chronic  inflammation  of  the  ribs  which  follows  typhoid  fever  is  an 
example  of  this  class  of  cases  (see  page  617j.  The  other  chronic  in- 
flammations of  bone  are  mostly  secondary  to  preceding  acute  inflam- 
mations, and  include,  as  a  terminal  stage  of  the  latter,  necrosis.  Chronic 
inflammations  of  bone  are  also  sometimes  the  result  of  the  extension 
to  the  latter  of  chronic  inflammation  in  the  surrounding  parts.  The 
changes  which  occur  in  bone  in  consequence  of  chronic  inflammation 
consist  either  in  a  destruction  of  the  bone  substance  (caries,  necrosis) 
or  in  a  reactive  new  formation  of  bone. 

Chronic  Periostitis. — Among  the  various  forms  of  chronic  perios- 
titis, mention  should  flrst  be  made  of  the  chronic  fibrous  form.  In 
this  variety  tough,  fibrous  thickenings  of  the  periosteum  develop, 
sometimes  with  absorption  of  the  superficial  portions  of  the  bone  (caries 
superficialis),  and  sometimes  with  new  formation  of  bone.  In  the  lat- 
ter instance  the  process  is  an  ossifying  periostitis. 

Periostitis  Albuminosa  or  Mucinosa  (Non-purulenta). — Poncet  and  Oilier 
were  the  first  to  describe  a  peculiar  form  of  periostitis  under  tlie  name  of 
periostitis  albuminosa  (ganglion  periostale),  concerning  the  nature  of  which 
different  authorities  hold  very  divergent  views.  The  affection  attacks  almost 
exclusively  the  ends  of  the  diaphysis  of  the  long,  hollow  bones  in  young  sub- 


(314  IN'JURIES  AND  SURGICAL  DISEASES  OF  BONE. 

jects  from  fifteen  to  twenty  years  of  age,  and  involves  not  only  the  periosteum 
but  frequently  the  bone  also  (ostitis  albuminosa).  Schlange  has  proposed 
calling  it  periostitis  and  ostitis  non-purulenta,  and  Rieding-er  periostitis  mu- 
cinosa. As  a  rule,  the  disease  begins  with  severe  pain,  swelling  at  the  lower 
end  of  the  diaphysis  in  the  neighbourliood  of  the  epiphyseal  line,  and  fever, 
as  is  the  case  in  acute  primary  osteomyelitis.  After  a  few  days  the  fever  and 
pain  disappear,  and  the  swelling  of  the  periosteum  and  bone  becomes  more 
and  more  prominent.  There  will  be  found  at  the  diseased  point,  instead  of 
pus,  either  a  bloody  serous  or  a  hydi'ocele-  or  sy  no  vial-like  fluid  which  has 
the  consistency  of  tenacious  mucus.  The  fluid  lies  either  beneath  the  peri- 
osteum, or  within  it  in  the  form  of  a  cyst,  or  on  its  outer  surface,  and  in  the 
latter  instance  there  is  also  a  diffuse  o^dematous  swelling  of  the  surrounding 
soft  parts.  In  my  opinion  the  disease  is  at  the  outset  an  acute  or  subacute 
non-suppurative,  non-serous  osteomyelitis  and  periostitis,  which  is  not  a  dis- 
ease sui  generis,  but  is  caused  by  various  factors,  particularly  by  attenuated 
pus  cocci  (staphylococci)  ;  in  some  cases  it  may  be  of  tubercular  or  syphi- 
litic nature.  Dor  found  in  one  case  the  Bacillus  cereus  citreus.  Vollert 
states  that  a  mucoid  metamorphosis  of  the  leucocytes  takes  place  in  this 
affection.  Its  course  is  very  chronic,  atid  necrosis  of  the  bone  is  often  pres- 
ent. The  disease  is  very  rebellious  to  therapeutic  measures  and  recurrences 
frequently  take  place,  or  fistulas  may  persist  for  months  or  years.  The  best 
treatment  consists  in  incision  and  energetic  scraping  out  of  the  underlying 
diseased  bone,  with  or  without  chiselling  an  opening  into  the  medullary 
cavity.     Cystic  formations  should  be  carefully  extirpated. 

In  the  chronic  ossifying  periostitis  the  new  formation  of  bone  is 
either  limited  to  a  circumsci'ibed  portion  of  the  bone,  giving  rise  to 
wliat  is  called  an  osteophyte  (Fig.  413),  or  diffuse  hypertrophies — hyper- 


Fig.  413. — Osteophj'te  (Patholofrical  Museum  at  Leipsic). 

ostoses,  as  they  are  called — are  developed,  in  consequence  of  which 
thickenings  of  the  bone  resembling  elephantiasis  result  (Fig.  414). 

In  addition  to  chronic  ifibrous  and  chronic  ossifying  periostitis,  we 
recognise  a  chronic  suppurative  periostitis,  which  sometimes  is  the 
terminal  stage  of  an  acute  periostitis  and  sometimes  develops  gradually 
as  a  disease  by  itself,  and  chiefly  comes  into  consideration  as  a  con- 
comitant phenomenon  of  necrosis  or  caries  of  bone.  In  chronic  sup- 
purative periostitis  we  have  to  deal,  for  the  most  part,  with  specific 


105.] 


THE   CHRONIC  INFLAMMATIONS   OF  BONE. 


645 


processes,  sucli  as  tuberculosis,  syphilis,  or  actinomycosis,  and  also 
with  necrosis  of  bone  from  various  causes.  Tubercular  periostitis  is 
either  primary  or  secondary  to  tuber- 
culosis of  bone  or  its  medulla,  or  of 
the  surrounding  soft  parts. 

Treatment  of  Cliroiiic  Periostitis. — 
Chronic  non-suppurative  periostitis 
should  be  treated  briefly  as  follows : 
First  of  all  its  cause  should  be  deter- 
mined and  proper  steps  taken  to  rem- 
edy it.  To  relieve  the  tension,  pain, 
and  local  inflammatory  symptoms,  in- 
cisions and  hydropathic  applications 
can  be  used  with  advantage.  It  is  also 
an  excellent  plan  to  paint  the  parts 
with  tinct.  iodi  fortior  alcoh.  (five 
parts  iod.  pur.  to  30.0  of  alcohol). 
Compression  by  the  elastic  bandage 
is  of  use  for  the  fibrous  thickening  and 
osteophytes ;  but  troublesome  osteo- 
phytes, occurring,  for  example,  in 
connection  with  an  ulcer  of  the  leg 
or  some  other  disease  of  the  soft  parts, 
should  be  removed  with  the  hammer 
and  chisel. 

The  treatment  of  chronic  suppu- 
rative  periostitis   is  likewise  mainly 
determined  by  the  cau3e,  and  we  shall 
discuss  this  disease  more  fully  under  Tuberculosis,  Caries,  Necrosis, 
etc.  (see  also  Syphilis,  §  84,  and  page  652). 

Tuberculosis  of  Bone. — One  of  the  most  important  and  by  far  the 
most  common  of  chronic  bone  diseases  is  tuberculosis  (ostitis  tubercu- 
losa, cai-ies  tuberculosa  or  fungosa),  which  occurs  chiefly  as  tubercular 
periostitis  and  osteomyelitis,  and  leads  to  extensive  destruction  of  bone 
—to  caries,  as  it  is  called  (Fig.  415)— and  to  necrosis.  Yolkmann, 
Billroth,  Konig,  Oilier,  and  others  have  won  lasting  honours  by  their 
studies  upon  the  subject  of  tuberculosis  of  bones  and  joints,  and 
Eobert  Koch  has  greatly  advanced  our  knowledge  of  the  etiology 
of  tubercular  inflammation  by  demonstrating  and  obtaimng  in  pure 
cultures  the  tubercle  bacillus  (§  83).  We  now  know  that  all  those 
forms  of  inflammation  which  affect  bone,  and  have  been  designated 
as  caries,  spina  ventosa,  scrofulous  or  fungous  inflammation  of  bones 


Fig.  414. — Hyperostosis  (elephantiasis)  of 
the  femur  (Pathological  Museum  at 
Leipsic). 


Q4:6 


INJURIES   AND   SURGICAL   DISEASES   OP  BONE. 


and  joints,  tumor  albus,  etc.,  are  in  the  main  true  tuhercular  inflam- 
mations. 

Tubercular  inflammation  of  bone  occurs  most  commonly  in  young 
individuals — i.  e.,  in  growing  bune — for  the  reason  mentioned  before, 
nameh',  that  the  formed  foreign  elements  circulating  in  the  blood,  par- 
ticularly the  tubercle  bacilli,  are  more  readily  deposited  in  the  l)ranches 
of  the  vessels  in  growing  bone,  although  tuberculosis  also  occurs  dur- 
ing the  later  years  of  life,  and  may  be  met  with  even  in  extreme  old 
age.  The  poison  of  tuberculosis,  the  tubercle  bacilli,  are  generally 
carried  to  the  bones  by  means  of  the  blood-vessels,  as  can  be  easily 
proved  by  experiments  on  animals.  Injuries  of  bone,  as  we  remarked 
before,  favour  the  development  of  tuberculosis.  Tuberculosis  of  bone 
may,  moreover,  be  due  to  the  direct  extension  to  the  latter  of  a  tuber- 
cular process  in  the  surrounding  tissues,  such  as  the  skin,  subcutaneous 
tissue,  tendon  sheaths,  synovial  membrane,  etc.  Tubercular  inflamma- 
tions of  the  vertebrae  and  of  the  bones  of  the  hands  and  feet  are  the 
most  common. 

Anatomical  Changes  in  Tuberculosis  of  Bone.— Tuberculosis  of  bone 
almost  always  begins  with  the  formation  of  circumscribed  foci  in  the 
periosteum,  in  the  epiphyses  of  the  long  bones,  in  the  medulla,  or  in  the 
spongiosa  of  the  short  bones  (Fig.  351) ;  less  commonly  the  disease  is  more 


Fig.  415. — Tuberculosis  of  the  lower  epiphysis 
of  the  femur,  with  two  sequestra  («).  The 
process  has  broken  through  into  the  knee- 
joint  (Weber). 


.0  0  fie^t 


) 


-Tn 


Fig.  416. — Fungous  granulations  with  tuber- 
cles (Tu)  in  the  cancellous  portion  of  the 
talus  :  A',  intact  trabecula  of  bone. 


diifuse.  The  tubercular  ^ocus  often  remains  for  a  long  time  the  size  of  a 
pea  or  a  hazel-nut,  and  then  enlarges  by  direct  extension  from  its  edges  or 
by  the  development  of  new  foci  in  the  region  surrounding  the  primary 
one.  The  individual  foci  then  coalesce,  and  thus  large  tubercular  areas 
originate.     Not  infrequently  several  distinct  foci  are  observed  in  one  and 


§105.]  THE   CHRONIC  INFLAMMATIONS  OF  BONE.  547 

the  same  bone,  or  tubercular  inflammations  occur  in  different  bones  at  the 
same  time  or  one  after  the  other.  The  tubercular  focus  is  made  u]3  of  the 
characteristic  tubercles  which  originate  from  the  lodgment  and  growth 
of  the  tubercle  bacilli,  and  have  been  minutely  described  on  page  415. 
Wherever  a  tubercle  focus  develops  in  bone  (Figs.  415  and  416),  caries 
results — i.  e.,  the  bone  disappears  in  the  form  of  lacunar  absorption  (see 
Fig.  401) — while  the  focus  itself  sooner  or  later  becomes  the  seat  of  a 
cheesy  degeneration  beginning  in  its  centre.  If  the  bone  has  not  been 
destroyed  at  the  time  that  caseation  of  the  tubercular  focus  occurs,  death  of 
the  bone  then  takes  place  m  toto — i.  e.,  a  so-called  tubercular  sequestrum 
forms  which  becomes  separated  from  the  surrounding  parts  by  a  demarcat- 
ing suppuration.  In  the  later  stages  the  tubercular  sequestrum  lies  com- 
pletely free  in  a  cavity  of  greater  or  less  size,  containing  cheesy,  flocculent 
pus,  vfith  or  without  fistulse  opening  externally  (Fig.  415).  In  general  the 
characteristic  tubercular  sequestrum  is  a  larger  or  smaller  caseated  concre- 
tion of  bone  through  w^hich  has  grown  tubercular  or  caseous  granulation 
tissue.  Very  often  the  entire  tubercular  focus  becomes  softened  and  lique- 
fied in  toto  without  the  formation  of  a  sequestrum.  The  central  abscesses  of 
bone,  which  exist  for  years,  are  partly  due  to  tubercular  processes,  partly  to 
a  preceding  primary  acute  infectious  osteomyelitis,  and  partly  to  metastasis 
in  the  course  of  acute  infectious  diseases. 

A  reactive  formation  of  bone  often  takes  place  around  the  tubercular 
focus  in  the  bone  or  its  medulla,  causing  it  to  become  more  or  less  com- 
pletely enclosed  by  thickened,  sclerotic  bone  tissue.  In  the  pronounced  cases 
of  sclerosis  of  bone  the  bony  structure  becomes  as  dense  as  ivory  (so-called 
eburnatio  ossis),  and  the  medullary  cavity  may  be  completely  obliterated. 
But  in  other  instances  all  traces  of  reactive  hyperplasia  of  bone  are  absent, 
even  though  the  tubercular  inflammation  has  existed  for  years. 

In  some  cases  there  are  also  formed  sacculated  collections  of  pus — 
cold  abscesses — which  are  enclosed  in  a  characteristic  so-called  pyogenic 
membrane  consisting  of  connective  tissue  and  tubercular  granulation  tissue. 
The  abscesses  either  rupture  externally  in  the  region  where  they  originated, 
or  the  force  of  gravity  causes  them  to  sink  lower.  In  the  case  of  tubercular 
inflammation  of  the  dorsal  vertebrae,  for  example,  they  descend  along  the 
anterior  surface  of  the  vertebrae,  following  the  course  of  the  psoas  muscle, 
and  appear  beneath  Poupart's  ligament  (so-called  spinal  abscesses).  These 
spinal  abscesses  extend  in  a  perfectly  typical  manner,  which  is  governed  by 
the  anatomical  conditions — i.  e.,  they  follow  the  natural  spaces  between  the 
tissues  corresponding  to  the  arrangement  of  the  fasciae  and  aponeuroses. 

The  caries  which  accompanies  tuberculosis  is  often — in  the  case  of  the 
vertebrae,  for  example — very  considerable.  In  consequence  of  this  there 
develops  in  the  back  the  so-called  kyphosis  or  Pott's  hump,  named  after 
the  English  surgeon  Percival  Pott,  who  first  described  this  disease.  Marked 
destructive  changes  also  take  place  in  the  small  bones  and  articular  ends  of 
the  long  ones,  leading  to  deformities  of  various  kinds,  with  subluxations  and 
complete  dislocations  of  the  deformed  articular  extremities  of  the  bones.  In 
the  fingers  and  toes  tuberculosis  usually  occurs  as  a  tubercular  osteomyelitis, 
with  a  spindle-shaped  enlargement  of  the  bone  {sjiina  ventosa).  In  this  con- 
dition the  cortex  of  the  bone  becomes  constantly  thinner  in  consequence  of 


(US  INJURIES  AND  SURGICAL   DISEASES   OF  BONE. 

the  tubercular  osteomyelitis,  while  at  the  same  time,  as  a  result  of  the  reactive 
periostitis,  osteophytes  are  formed.  Spina  ventosa  often  heals  without  sup- 
puration or  necrosis  having  taken  place,  and  with  a  spontaneous  and  com- 
plete restitutio  ad  integrum.^  The  same  form  of  tuberculosis  also  occui's  in 
the  long-  bones,  such  as  the  tibia  and  femur. 

The  most  common  site  of  bone  tuberculosis  in  the  long  bones,  whether 
located  in  the  periosteum  or  in  the  interior  of  the  bone,  is  in  tlie  region  of 
the  epiphyses.  This  is  tlie  reason  why  secondary  tuberculosis  of  the  joints 
is  so  common  (see  §  114,  Tuberculosis  of  Joints).  Tuberculosis  of  the  diaphy- 
sis  of  a  bone  is  comparatively  rare — a  fact  of  great  diagnostic  importance, 
especially  in  the  case  of  adults.  Consequently,  if  the  shaft  of  a  bone  is 
diseased,  particularly  in  an  adult,  we  think  of  sj-philitic  or  some  other  bone 
disease  before  tuberculosis. 

As  regards  other  bones,  tuberculosis  is  especially  common  in  the  bones  of 
the  skull,  in  the  orbital  portion  of  the  superior  maxilla,  in  the  ribs,  and  par- 
ticular-ly  in  the  spinal  column  and  the  bones  of  the  carpus  and  tarsus. 

The  microscopical  changes  in  tuberculosis  of  bone  (Fig.  416)  are  the  same 
as  in  tubercular  inflammation  elsewhere.  Koch's  tubei'cle  bacilli  will  be 
found  most  abundantly  where  the  tubercular  process  is  beginning,  the  best 
method  of  staining  being  that  of  Ehrlich\s,  with  fuchsin  or  gentian  violet. 
Nevertheless,  their  demonstration  in  tuberculosis  of  bone  is  sometimes  very 
difficult,  or  even  impossible — a  fact  which  we  noted  befoi'e.  In  tuberculosis 
of  bones  and  joints  Miiller  frequently  found  peculiar  bodies  resembling  fat 
drops,  which  not  uncommonly  were  surrounded  by  minute  granules,  and,  like 
these,  were  characterised  by  taking  on  a  deep  red  or  violet  stain.  These 
bodies  probably  bear  some  relationship  to  the  bacilli. 

The  Clinical  Course  of  Bone  Tuberculosis. — The  clinical  course  of 
tuberculosis  of  bone  is  usually  very  chronic.  There  are  often  symp- 
toms of  tuberculosis  in  other  organs — the  lungs,  for  instance — at  the 
same  time.  Heredity  is  important — i.  e.,  tuberculosis  of  the  parents  or 
grandparents  or  other  near  relatives.  Quite  often  it  happens  that  for 
a  long  time  symptoms  peculiar  to  tubei'culosis  of  bone  are  absent ;  severe 
pain  especially  may  long  be  missed,  unless  a  neighbouring  joint,  the 
periosteum,  or  overling  parts  are  attacked  by  the  tubercular  iuliam- 
mation.  In  the  majority  of  instances  the  symptoms  pointing  to  tuber- 
cular inflammation  will  not  make  their  appearance  till  after  the  disease 
has  existed  for  months,  the  development  of  an  appreciable  tumour,  par- 
ticularly if  the  tuberculosis  is  periosteal,  being  the  first  intimation  of 
the  process.  But  even  if  the  tuberculosis  is  located  in  the  bone  or 
medullary  cavity,  an  appreciable  tumour  will  sometimes  be  formed  after 
several  months  in  consequence  of  a  thickening  of  the  bone,  while  in 
other  instances,  though  the  tuberculosis  may  have  existed  for  years,  all 
swelling  \vill  be  absent.  Under  these  conditions  the  diagnosis  can  often 
only  be  made  when  the  periosteum  begins  to  become  involved  in  the 
inflammation,  and  there  is  tenderness  on  pressure  over  the  area  in. 


§  105.]  THE   CHRONIC   INFLAMMATIONS   OF   BONE.  649 

question,  or  when  oedema  of  the  skin  is  present.  As  the  tuberculosis 
advances  the  symptoms  become  more  pronounced,  especially  the  swell- 
ing at  the  diseased,  spot,  the  pain,  particularly  if  the  tuberculosis  is 
located  in  the  medulla,  the  disturbance  of  function,  the  development 
of  fistulse,  burrowing  of  pus,  etc.  The  disturbance  of  function  is  most 
pronounced  in  tuberculosis  of  the  epiphysis  in  the  neighbourhood  of  a 
large  joint  like  the  hip  or  knee.  The  tumefaction  accompanying  tuber- 
cular infiltration  of  the  periosteum  or  medulla  is  either  due  to  osteo- 
phyte formation,  or  the  bone  is  pufied  out,  as  it  were,  by  tubercular 
osteomyelitis,  in  the  manner  which  we  described  as  occurring  in  spina 
ventosa  of  the  phalanges  of  the  fingers.  In  this  spina  ventosa  of  the 
fingers  the  bone  may  feel  firm,  or  elastic  and  thin.  After  a  certain 
length  of  time  the  tubercular  pus  works  its  way  outwards  and  breaks 
spontaneously  through  the  skin,  and  the  thin  liquid,  usually  mixed  with 
cheesy  flocculi,  is  discharged.  Fistulous  ulcers  with  a  cheesy  base  and 
undermined  edges  then  develop  from  the  fistulse.  If  a  probe  is  passed 
through  the  fistula  it  either  immediately  comes  in  contact  with  the 
bone,  or  penetrates  into  the  medullary  cavity.  The  other  secondary 
manifestations  of  tuberculosis,  the  cold  or  congestion  abscesses,  etc., 
have  been  sufficiently  described,  and  we  need  only  call  attention  to  the 
fact  that  the  latter  do  not  heal  up  until  the  original  focus  which  gave 
rise  to  them  has  disappeared.  Their  course  is  usually  very  tedious, 
especially  in  the  case  of  tubercular  inflammation  of  the  spine.  The 
tubercular  inflammations  of  joints  are  discussed  in  §  114.  A  tubercu- 
lar deposit  in  the  periosteum  or  medulla  of  an  epiphysis,  lying  in  im- 
mediate proximity  to  a  joint,  often  works  its  way  to  the  surface  extra- 
articularly^  and  leaves  the  joint  intact. 

The  general  health  in  tuberculosis  of  bone  is  very  often  but  little 
or  not  at  all  affected.  There  is  frequently  a  slight  fever,  varying  with 
the  extent  of  the  process.  It  is  a  common  occurrence  to  find  that  the 
general  health  is  only  slightly  disturbed  even  when  extensive  multiple 
tuberculosis  is  present.  In  general  the  fever  is  most  pronounced 
hefore  the  tubercular  inflammation  has  extended  beyond  the  bone,  but 
it  is  usually  slight,  and,  as  a  rule,  disappears  more  or  less  completely 
when  the  inflammation  has  worked  its  way  to  the  surface  of  the  body. 
High  fever  is  most  likely  to  occur  in  case  of  secondary  infection  with 
pus  cocci. 

Diagnosis  of  Bone  Tuberculosis. — The  diagnosis  of  tuberculosis  of  bone  is 
easy  in  the  case  of  primary  tubercular  periostitis,  particularly  if  the  bone  is 
superficial,  and  the  characteristic  swelling,  tenderness  on  pressure,  etc.,  are 
present.  The  diagnosis  of  bone  tuberculosis  may  occasionally  be  doubtful 
for  some  time,  but  still  its  beginning  and  subsequent  course  in  different  parts 


650  INJURIES  AND  SURGICAL   DISEASES  OF   BONE. 

of  the  body,  as  we  shall  see  in  the  Regional  Surgery,  is  generally  so  typical 
that  tlie  diagnosis  is  not  very  difficult  (see  also  §  83,  Tuberculosis). 

Prognosis  of  Bone  Tuberculosis.— As  regards  the  termination  and  the 
prognosis  of  tuberculosis  of  bone,  I  must  refer  the  reader  to  what  has  been 
stated  in  §  83.  Suffice  it  to  say  that  the  location  of  tuberculosis  of  bone  plays  a 
very  important  part  as  regards  prognosis — i.  e.,  in  so  far  as  it  determines 
whether  the  existing  focus  can  be  completely  removed  by  operative  measures 
at  the  earliest  possible  stage,  or  whether  other  local  treatment,  such  as  iodo- 
form injections,  can  be  employed.  If  the  latter  is  impracticable,  as  may 
often  be  the  case  in  tuberculosis  of  the  vertebrte,  spontaneous  recovery  can 
probably  only  take  place  when  the  focus  is  not  too  large.  In  the  majority 
of  instances  the  tubercular  disease  steadily  progresses  or  very  often  leads  to 
tubercular  systemic  infection.  Recurrences  in  tuberculosis  are  pretty  com- 
mon, and  permanent  cui'es  do  not  occur  so  frequently  as  many  enthusiasts 
believe  (see  §  83). 

The  Treatment  of  Tuberculosis  of  Bone. — In  the  first  stages  of  a 
developing  tuberculosis  of  bone  the  treatment  is  purely  symptomatic 
(rest,  immobilising  dressings,  ice,  good  food,  fresh  air,  etc.).  As 
soon  as  possible  I  then  begin  in  suitable  cases  parenchymatous 
injections  of  sterilised  ten  per  cent,  iodoform  oil,  or  the  iodoform 
glycerine  of  Bruns,  which  I  can  most  heartily  recommend  (two  to 
eight  grammes  every  two  to  four  weeks).  The  iodoform  and  oil  are 
sterilised  separately  by  heating  them  in  a  sterilising  apparatus  to  100° 
C.  (212°  F.) ;  the  sterilised  materials  are  then  cooled  and  made  into  a 
ten  per  cent,  iodoform  mixture  in  a  sterilised  vessel.  Instead  of  ol. 
olivse,  Bohm  recommends  ol.  amygd.  dulc,  in  which  is  dissolved  fifty 
per  cent,  of  iodoform.  If  the  iodoform  oil  is  prepared  in  the  manner 
described  above,  we  avoid  the  injurious  effects  or  poisonous  manifesta- 
tions of  the  iodoform,  which  are  mainly  caused  by  the  liberation  of 
iodine.  The  latter  is  particularly  apt  to  be  set  free  if  the  iodoform 
and  oil  are  sterilised  together  at  high  temperatures  when  in  the  form 
of  an  emulsion.  Lannelongue  praises  the  results  obtained  by  the  injec- 
tion of  sti'ong  solutions  of  chloride  of  zinc  into  the  periphery  of  the 
tubercular  focus ;  a  contracting,  cicatrix-like  tissue  is  thus  produced, 
which  forms  an  obstruction  to  the  spi'ead  of  the  tubercular  process  and 
causes  the  death  of  the  tubercular  focus.  I  have  little  to  say  in  favour 
of  parenchymatous  injections  of  three-per-cent.  solutions  of  carbolic 
acid  or  arsenic.  Kannotti  recommends  oil  of  cloves  (ten  per  cent., 
with  olive  oil) ;  Eeboul,  naphthol  camphre  obtained  by  mixing  and 
heating  one  hundred  parts  of  finely  powdered  ;8-naphthol  with  two 
hundred  parts  of  finely  powdered  Japan  camphor.  The  oily  liquid  of 
naphthol  camphre  is  insoluble  in  water,  but  miscible  with  fats,  ether, 
alcohol,  and  chloroform,  and  must  be  kept  in  a  dark  bottle.  The 
remedy  can  be  employed  in  various  ways — as  a  wash,  an  injection,  etc. 


§  105.]  THE  CHRONIC   INFLAMMATIONS  OP   BONE.  651 

Bouchard  states  that  its  toxic  dose  for  adults  is  about  two  hundred 
and  fifty  grammes.  For  other  remedies,  including  cinnamic  acid,  see 
page  429. 

If  treatment  by  drugs  proves  unsuccessful,  and  a  distinct  focus  of 
disease  or  of  pus  is  present,  operative  treatment  should  be  undertaken — 
i.  e.,  the  tubercular  deposit  should  be  removed  as  soon  as  possible,  with 
strict  regard  to  antisepsis.  Operations  on  the  extremities  are  performed 
with  the  use  of  an  Esmarch  bandage,  which  renders  it  possible  to  easily 
distinguish  the  healthy  from  the  diseased  parts.  A  free  incision  should 
always  be  made,  in  order  that  the  focus  may  be  inspected  throughout 
its  entire  extent.  Electric  illumination  is  often  useful  for  this  purpose. 
If  the  tuberculosis  is  in  the  medulla,  the  bone  should  be  opened  suf- 
ficiently with  the  chisel  and  hammer,  and  the  tubercular  focus  ener- 
getically scraped  out  with  the  sharp  spoon.  The  scraping-out  process 
must  be  continued  until  healthy,  firm  bone  is  reached.  Even  when 
the  entire  medullary  cavity  of  a  long  bone  has  to  be  thus  scraped  out, 
necrosis  will  not  occur  if  only  the  wound  in  the  bone  heals  aseptically. 
To  prevent  recurrences  and  to  render  speedy  recovery  possible,  exten- 
sive removal  of  the  bone  is  advisable,  leaving  only  a  thin  wall  of  cortex 
intact.  Free  sequestra  should  be  extracted  ;  infected  soft  parts  in  the 
neighbourhood  of  the  diseased  bone,  abscess  membranes,  etc.,  should 
likewise  be  removed  with  the  greatest  care  by  scissors  and  forceps. 
After  having  scraped  out  the  tubercular  deposit  in  the  bone,  the  result- 
ing cavity  should  be  filled  with  ten  per  cent,  iodoform  oil  and  packed 
with  iodoform  gauze,  Billroth's  method  is  most  excellent  and  efiica- 
cious.  The  tubercular  cavity,  in  case  it  has  not  opened  externally 
before  the  operation,  is  immediately  filled  with  ten  per  cent,  iodoform 
oil  or  iodoform  glycerine,  and  hermetically  closed  after  all  tubercular 
tissue  has  been  removed  with  the  sharp  spoon.  The  iodoform  acts 
more  effectively  in  the  absence  of  air. 

If  any  recurrences  take  place,  they  are  soon  recognised  by  the  per- 
sistence of  fistulas  with  fungous  tissue.  The  secondary  operation  should 
not  be  delayed  too  long.  Operations  must  often  be  performed  two, 
three,  or  more  times,  with  short  intervals,  before  a  complete  cure  is 
obtained.  The  cold  abscess,  which  used  to  be  a  noli  me  tangere  to  the 
old  surgeons  on  account  of  the  pyaemia  which  so  frequently  followed 
the  operation,  must  always  be  opened  at  the  earliest  possible  moment, 
scraped  out  and  drained ;  or,  after  evacuation  of  the  pus,  iodoform 
emulsion  may  be  injected  into  the  cavity  and  the  incision  closed  by 
sutures.  The  treatment  of  tubercular  inflammations  of  joints  will  be 
discussel  under  the  subject  of  Diseases  of  Joints  (§  114).  The  indi- 
cations for  amputation  and  resection  are  described  on  pages  119  and 


652  INJURIES  AND  SURGICAL  DISEASES  OF   BONE. 

135.  All  operations  in  cases  of  tuberculosis  should  be  performed  with 
the  greatest  care  and  most  rigid  asepsis.  We  mentioned,  in  tirst  speak- 
ing of  tuberculosis,  that  general  miliary  tuberculosis  may  occasionally 
follow  operations  on  tubercular  foci,  as  well  as  vigorous  movements  of 
joints  affected  with  tubercular  disease. 

Iodoform  and  iodoform  gauze  are  the  best  materials  for  dressings 
in  cases  of  tuberculosis,  and  large  wounds  may  be  packed  with  them. 
Instead  of  packing  with  iodoform  gauze,  Schede's  plan  of  obtaining 
healing  under  an  aseptic  blood-clot  without  drainage  is  also  very 
serviceable  after  scraping  out  the  tubercular  deposit  (see  page  1U9). 

The  treatment  of  tuberculosis  of  bone  with  Koch's  tuberculin  is 
discussed  on  page  421.  I  have  obtained  no  permanent  cures  by  this 
means,  and  sometimes  matters  have  been  made  decidedly  worse.  Other 
surgeons  have  had  the  same  experience. 

In  tubei'culosis  it  is  very  important  that  the  constitution  of  the 
patient  should  be  strengthened  by  energetic  general  treatment,  in  the 
manner  described  on  pages  -120  and  IrS-l. 

The  Syphilitic  Diseases  of  Bone. — Syphilis  of  bone  occurs  in  the 
later  stages  of  the  disease  (§  84),  either  in  the  form  of  death  of  bone, 
as  caries  and  necrosis,  or  as  an  ossifying  inflammation  of  bone.  The 
inflammation  of  bone  characteristic  of  syphilis  is  the  gummatous  perios- 
titis and  osteomyelitis — i.  e.,  the  formation  of  gummata  or  syphilomata 
in  the  periosteum  or  medulla.  The  periosteal  gummata  take  the  form 
of  flat,  elastic  swellings,  which  on  section  reveal  a  gelatinous  consist- 
ency. In  the  later  stages  a  fatty,  cheesy,  or  a  suppurative  degenera- 
tion takes  place,  with  or  without  shrinkage,  to  firm  fibrous  thickenings. 
The  periosteal  gumma  is  very  apt  to  occur  on  the  skull,  and  also  not 
infrequently  in  the  periosteum  inside  the  cranial  cavity,  less  often  on 
the  clavicle,  and  rarely  on  the  diaphyses  of  the  long  bones.  The 
epiphyses  of  the  latter  and  the  short  bones  are,  almost  without  excep- 
tion, exempt  from  gummata. 

The  osteomyelitic  gummatous  nodes  are  soft  or  more  fibrous  gelat- 
inous formations,  varying  from  about  the  size  of  a  pea  to  that  of  a 
nut,  and  usually  cheesy  in  the  centre.  They  are  sometimes  multiple, 
being  found,  for  example,  on  the  skull,  on  the  phalanges,  and,  accord- 
ing to  Chiari,  also  on  the  long  bones,  the  femur  and  tibia  being  the 
most  frequently  affected. 

Both  periosteal  and  osteomyelitic  gummata  destroy  the  bone  to  a 
greater  or  less  extent,  and  lead  to  a  varying  amount  of  superficial  or 
central  caries  with  necrosis.  In  consequence  of  this  death  of  bone 
fractures  readily  occur,  and  not  infrequently  are  followed  by  pseudar- 
throsis.     The  syphilitic  caries  with  necrosis  is  particularly  apt  to  make 


§105.]  THE   CHRONIC  INFLAMMATIONS   OF   BONE.  653 

its  appearance  on  the  skull,  and  sometimes  is  very  extensive  (see 
Eegional  Surgery).  A  reactive  new  formation  of  bone  also  occurs  as 
a  result  of  the  gummatous  periostitis  and  osteomyelitis ;  it  leads  to  the 
development  of  osteophytes  of  varying  dimensions,  and  also  to  hyper- 
trophy and  sclerosis  of  the  bone. 

The  gummata  either  disappear  under  appropriate  antisyphilitic 
treatment  by  becoming  gradually  absorbed  and  replaced  by  dense  cica- 
tricial tissue  or  newly  formed  bone  tissue,  or  else  a  spreading  destruc- 
tion and  necrosis  of  bone  develops,  the  gummata  open  externally,  etc. 

Apart  from  the  reactive  development  of  new  bone  with  the  forma- 
tion of  osteophytes  and  diffuse  hyperostoses  accompanying  gummata, 
there  is  also  an  independent  ossifying  syphilitic  ostitis,  a  periostitis 
and  osteomyelitis,  which  occur  alone. 

In  congenital  syphilis  there  is  observed  a  characteristic  disease  of 
the  bones  in  the  neighbourhood  of  the  epiphyses,  consisting  in  some 
cases  in  an  abnormity  in  the  deposit  of  lime,  and  in  the  formation  of 
medullary  spaces  such  as  occurs  in  rhachitis.  This  syphilitic  rhachitis 
is  not  very  common.  But  in  other  cases  of  congenital  syphilis  a  very 
characteristic  locahsed  disease  is  present  in  the  epiphyses,  particularly 
in  the  part  near  the  articular  and  epiphyseal  cartilages.  This  syphilitic 
osteochondritis  of  infants,  first  described  by  Wegner,  is  in  fact  a  com- 
mon though  not  a  constant  manifestation  of  hereditary  syphilis.  The 
disease  consists  in  the  formation  of  greyish-red  or  yellowish-grey  foci 
in  the  medulla  of  the  epiphyses  in  the  neighbourhood  of  the  articular 
and  epiphyseal  cartilages.  The  bone  becomes  replaced  by  a  soft  granu- 
lation tissue,  and  the  cartilage  itself  is  in  a  state  of  inflammatory 
growth.  Separation  of  the  epiphysis  sometimes  occurs  in  syphilitic 
osteochondritis,  as  it  does  after  acute  infectious  osteomyelitis.  Kasso- 
witz  found  this  condition  nine  times  in  thirty-three  cases.  Epiphyseal 
separations  have  also  not  infrequently  been  observed  in  still-born  syphi- 
litic children  (Haab,  Yeraguth,  etc.),  but  under  these  circumstances  the 
separations  may  possibly  have  been  caused  by  putrefactive  changes  as 
well  as  by  the  syphilitic  osteochondritis. 

The  course  of  the  syphilitic  inflammations  of  bone,  which  occur 
especially  in  the  later  so-called  tertiary  period  of  the  disease  and  in  the 
cases  which  have  been  improperly  treated,  is  for  the  most  part  very 
chronic  and  marked  by  frequent  relapses.  They  have  been  wrongly 
ascribed  to  the  effects  of  mercury.  Ostitis  due  to  mercury  is  only  ob- 
served as  a  result  of  salivation  ulcers  on  the  jaws.  Traumatism  appears 
to  play  an  important  part  in  the  syphilitic  inflammations  of  bone.  The 
severe  pains  (dolores  osteocopi),  which  occur  princip?Jly  at  night,  are 
often  characteristic. 


654  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

The  treatment  of  the  syphilitic  intiaimnations  of  bone  consists  in 
the  adoption  of  a  general  antisyphilitic  regimen  (see  §  84).  The  local 
treatment  of  the  syphilitic  metastases  is  conducted  according  to  general 
principles,  and  is  similar  to  that  brietly  described  for  tuberculosis 
of  bone. 

Chronic  Bone  Abscess.  — We  have  made  repeated  mention  of  the  so- 
called  chronic  bone  abscess  which  occurs,  for  example,  after  acute 
infectious  osteomyelitis  and  tuberculosis  of  bone.  It  is  always  infec- 
tious in  its  nature  and  arises  in  various  diseases,  and  is  not,  as  was 
once  believed,  an  independent  disease,  but  always  a  symptom  or  a 
result  of  a  pre-existing  specific  disease.  Hence  it  follows  that  the 
causes  of  abscess  of  bone  vary  greatly.  The  acute  suppurative  inflam- 
mations of  the  periosteum  and  medulla,  the  tubercular  and  the  syphi- 
litic inflammations  of  bone,  are  particularly  likely  to  give  rise  to 
the  development  of  chronic  bone  abscesses.  In  the  majority  of  cases 
acute  infectious  osteomyelitis  is  the  cause  of  chronic  Ijone  abscesses  ; 
the  pus  usually  contains  staphylococci  which  have  been  found  to  be 
virulent  even  after  the  abscess  has  existed  for  30  to  40  years.  Bloch 
has  reported  15  cases  of  chronic  bone  abscess  of  which  11  involved  the 
tibia  ;  the  time  intervening  between  the  primary  disease  and  admission 
to  the  hospital  varied  from  4  months  to  42  years  (once  11  years,  once 
12  years,  once  14  years,  three  times  16  years,  once  20  years,  and  once 
42  years). 

The  symptomatology  and  treatment  of  abscess  of  bone  can  be 
inferred  from  what  has  been  said  concerning  acute  and  chronic  suppu- 
ration of  bone. 

Other  Bone  Diseases:  Actinomycosis;  Glanders. — -Among  other 
chronic  diseases  of  bone,  I  should  mention  actinomycosis  and  the  cir- 
cumscribed cheesy  or  suppurative  inflammations  which  occur  in  the 
periosteum  and  medulla  in  the  course  of  glanders.  Both  diseases  have 
been  described  in  §  78  and  §  86. 

Ostitis  deformans. — Ostitis  deformans,  first  described  in  1876  by 
Paget,  Gzerny,  and  Eecklinghausen,  is  a  chronic  inflammation  of  bone 
occurring  in  adults  in  which  the  bones  always  remain  intact.  It  in- 
volves the  long  bones,  the  skull,  the  vertebrse,  and  the  pelvis,  and  is 
characterized  by  hypertrophy  and  softening  of  the  bone,  sometimes 
painful  and  sometimes  painless,  and  resulting  in  a  bending  of  the  same. 
Malignant  tumours  sometimes  develop.  Two  varieties  can  be  differen- 
tiated, a  painful  and  a  painless.  The  former  is,  the  more  common,  and 
begins  usually  in  the  lower  extremities,  with  thickening  and  subsequent 
bending  of  the  bone.  The  painless  variety  usually  begins  in  the  upper 
extremities  of  females.     The  disease  is  onh^  rarely  confined  to  single 


§  106.]  NECROSIS   OP  BONE.  655 

bones.  Thiberge  and  Joncheray  have  collected  60  cases  from  literature 
(40  from  the  English  and  15  from  the  French  literature).  The  average 
age  of  the  patients  was  about  50  years.  In  exceptional  cases  it  begins 
in  childhood.  The  etiology  of  the  afEection,  which  is  in  fact  a  bone 
disease  sui  generis,  is  not  clear.  Recklinghausen  classifies  the  disease 
closely  with  osteomalacia,  and  regards  it  as  a  decalcifying  process  in- 
volving the  entire  osseous  system,  with  attending  absorption  and  new 
formation  of  bone.  Yirchow  thinks  that  it  may  result  from  disturb- 
ances in  development.     The  treatment  is  symptomatic. 

§  106.  Necrosis  of  Bone. — "We  have  repeatedly  spoken  of  the  death 
or  necrosis  of  bone  or  of  a  certain  portion  of  bone  when  discussing  the 
subject  of  Injuries  and  Inflammations  of  Bone. 

The  causes  of  necrosis  of  bone  are  sometimes  inflammatory  and 
sometimes  traumatic  in  their  nature.  In  typical  necrosis  of  bone  there 
is  almost  always  an  interruption  of  the  afferent  flow  of  blood,  less  often 
a  direct  death  of  the  bone  substance.  Among  the  special  causes  of 
necrosis  the  diseases  of  the  periosteum  and  medulla  are  the  most  im- 
portant. Suppurative  periostitis  very  frequently  leads  to  necrosis ;  but 
every  suppurative  periostitis,  as  such,  will  not  cause  necrosis  of  bone 
until  it  has  existed  a  long  time  and  has  extended  to  the  contents  of 
the  Haversian  canals.  The  suppurative  periostitis  is  frequently  the 
result  of  a  necrosis  due  to  other  causes. 

Ils^ecrosis  is  also  produced  by  the  various  forms  of  ostitis  and  osteo- 
myelitis when  the  bone  tissue  becomes  unable  to  obtain  nourishment, 
owing  to  the  destruction  of  the  medulla  and  the  contents  of  the  Haver- 
sian canals.  In  this  class  of  cases  comes,  for  example,  the  necrosis 
from  suppurative  osteomyelitis  and  tuberculosis  of  bone,  mentioned  in 
a  previous  chapter. 

Suppurative  inflammations  of  the  surrounding  parts  and  ulcerative 
processes  which  extend  to  and  destroy  the  periosteum  likewise  lead  to 
necrosis.  In  this  manner  is  caused,  for  example,  the  necrosis  of  the 
nasal  bones,  which  occurs  in  the  course  of  syphilis  from  the  extension 
of  ulceration  in  the  nasal  mucous  membrane  to  the  deeper  parts  (ozsena 
syphilitica). 

The  necrosis  occurring  in  the  course  of  typhoid  fever  and  the  acute 
exanthemata  is  due  in  some  instances  to  metastatic  periostitis  and  osteo- 
myelitis, while  in  others  it  is  probably  a  kind  of  inanition  necrosis 
which  is  the  result  of  the  general  disturbance  of  nutrition.  As  a  mat- 
ter of  fact  the  state  of  the  nutrition  of  such  individuals  is  generally 
extremely  bad,  and  they  suffer  for  the  same  reason  from  gangrene  of 
the  ears  and  nose. 

In  rare  instances  necrotic  foci  in  bone  originate  from  emboli.    Yolk- 


656  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

mann  saw  a  multiple  necrosis  of  the  astragalus  and  tibia  which  followed 
the  formation  of  coagula  on  the  mitral  valve  in  endocarditis.  In  these 
cases  we  generally  have  to  do  with  multiple  capillary  emboli,  and  in  the 
case  of  infectious  processes  these  eml)oli  may  consist  of  micro-organ- 
isms which  have  entered  the  circulation.  Embolism  of  a  single  nutrient 
artery  of  the  bone  would  probably  never  be  followed  by  apprecialjle  con- 
sequences, for  the  reason  that  a  collateral  circulation  readily  develops, 
and  the  blood  is  carried  to  the  bone  by  very  many  and  for  the  most 
part  very  small  vessels. 

The  phosphorus  necrosis,  first  described  by  Lorinser,  of  A^ienna,  in 
1845,  is  extremely  interesting.  It  is  observed  in  people  employed  in 
the  manufacture  of  phosphorus  matches,  and  is  due  to  the  injurious 
effects  of  the  vapour  of  phosphorus.  Phosphorus  necrosis  only  affects 
the  bones  of  the  face,  and  selects  the  jaw  almost  always — the  inferior 
maxilla  more  frequently  than  the  superior.  The  disease  regularly  be- 
gins with  inflammatory  disturbances  in  the  periosteum  (phosphorus 
periostitis,  Wegner),  especially  where  there  are  diseased  (carious)  teeth. 
At  first  a  chronic  ossifying  periostitis  usually  develops,  then,  as  a  result 
of  infection  by  bacteria  in  the  oral  cavity,  suppuration  and  gangrene 
follow  between  the  periosteum  and  new  bone,  or  between  the  new  and 
old  bone.  Sometimes,  though  rarely,  the  disease  begins  immediately 
with  suppuration  and  necrosis  without  a  preceding  ossifying  periostitis. 
The  entire  lower  jaw  may  become  necrotic,  especially  if  the  process  is 
not  arrested  by  early  removal  of  the  focus  of  disease.  Hackel  states 
that  the  average  duration  of  the  disease  from  the  time  the  periostitis 
begins  till  the  suppuration  and  necrosis  of  the  under  jaw,  for  example, 
ceases,  is,  when  tlie  disease  is  left  to  itseK,  for  the  inferior  maxilla  two 
years  and  nine  and  a  half  months,  and  for  the  superior  maxilla  one  year 
and  two  months.  Since  the  manufacture  of  phosphorus  matches  has  be- 
come less  extensive,  and  strict  hygienic  regulations  have  been  enforced 
in  the  factories,  phosphorus  necrosis  has  become  rare ;  but  it  still 
occurs  in  regions  such  as  the  Thuringian  Forest,  where  the  making  of 
phosphorus  matches  is  carried  on  as  a  family  industry. 

iSTecrosis  develops  after  a  traumatism,  particularly  if  portions  of  the 
bone  are  completely  torn  off  or  separated  from  their  attachments — a 
fact  which  we  learned  when  discussing  fractures  (see  §  101).  AYe  stated 
at  that  time  that  in  fractures  which  heal  aseptically  and  in  those  which 
are  subcutaneous,  pieces  of  bone  which  have  been  completely  detached 
may  again  heal  in  place  and  not  undergo  necrosis.  After  subcutaneous 
dislocation  of  the  astragalus,  "Winiwarter  observed  total  necrosis  of  the 
bone  occur  in  two  instances  in  spite  of  its  having  been  carefully  re- 
placed.    Furthermore,  when  a  bone  has  been  severely  splintered  and 


§  106.]  NECROSIS  OF   BONE.  657 

crushed,  circumscribed  necrosis  is  particularly  apt  to  develop  if  tlie 
arterial  vessels  in  the  medullary  space  or  narrow  Haversian  canals  are 
compressed — by  an  extravasation  of  blood,  for  example.  Traumatic 
separation  of  the  periosteum  laying  bare  the  bone  does  not  of  itself 
lead  to  necrosis,  but  the  latter  will  develop  if  the  bone  becomes  dry 
from  long  contact  with  the  air,  or  if  suppuration  takes  place. 

Anatomical  Changes  in  Necrosis ;  Separation  of  the  Sequestrum  (Demar- 
cation).— When  a  portion  of  a  bone  has  perished  it  is  gradually  sepa- 
rated or  set  free  from  the  surrounding  living  bone  by  a  demarcating 
inflammation.  The  separation  of  the  dead  bone — the  demarcation,  as  it 
is  called — is  designated  anatomically  as  a  granulating,  rarefying  ostitis, 
the  bone  disappearing  by  lacunar  absorption  (see  Fig.  401)  along  the  line 
of  demarcation.  The  piece  of  bone,  after  it  has  become  completely  sepa- 
rated, is  called  a  sequestrum  (Fig.  417,  S).     The  outer,  periosteal,  cor- 


FiG.  417. — Complete  necrosis  of  the  diaphysis  of  the  tibia :  S,  sequestrum ;  a  a,  fistulse  (cloacae)  ; 
b,  newly  formed  bone  or  involucrum  (schematic). 

tical  surface  of  the  sequestrum  ordinarily  remains  smooth,  while  the 
other  portions  of  the  sequestrum,  where  it  is  gradually  set  free  from 
the  living  bone  by  the  demarcation,  appear  rough  and  uneven,  just 
like  the  ivory  pegs  which  have  been  driven  into  a  bone  for  pseudar- 
throsis  (see  Fig.  412).  The  size  of  every  sequesti'um  is  rendered  less 
by  this  corrosion  or  abrasion,  and,  in  fact,  small  sequestra,  like  small 
splinters  of  bone  in  fractures,  may  be  completely  absorbed  if  there  is 
no  suppuration  and  the  granulating  germinal  tissue  surrounds  them 
closely.  As  is  the  case  in  the  corrosion  of  the  ivory  pegs,  so  also  in 
the  separation  of  the  sequestra  and  the  absorption  of  small  sequestra 
it  is  mainly  the  carbonic  acid,  resulting  from  the  metabolism  of  the 
tissues,  which  in  the  free  state,  together  with  the  osteoclasts,  dissolves 
the  lime  salts.  The  length  of  time  occupied  by  the  process  of  demar- 
cation till  the  sequestrum  has  been  completely  separated  varies  greatly, 
and  depends  upon  the  size  of  the  sequestrum  and  its  location.  The 
activity  of  the  separating  process  in  different  individuals  is  also  very 
variable.  In  general  it  may  be  said  that  in  extensive  necrosis,  such  as 
the  total  necrosis  of  a  diaphysis,  the  sequestrum  requires  in  some  in- 
45 


G58 


INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 


Fig.  418. — Partial  necrosis  of  a  hollow  boue : 
H^  cavity  in  the  bone  after  removal  of  the 
sequestrum;  a,  fistula;  6,  newly  formed 
bone  or  involucrum  (schematic). 


stances  from  three  to  five  months,  and  in  others  from  eight  to  ten  to 
twelve  months,  before  it  is  completely  separated.  Separation  takes 
place  more  rapidly  in  yonng  than  in  old  patients. 

Hand  in  hand  with  the  separation  of  the  dead  portion  of  bone  its 
regeneration  proceeds  by  reactive  bone  formation — i.  e.,  by  an  ossifying 
periostitis  and  osteomyelitis — as  in  the  repair  of  fractures.  Through 
the  action  of  the  periosteum  a  capsule  of  bone — the  involucrum,  as 
it  is  called — is  formed  around  the  sequestrum,  in  the  case  of  necrosis 

of  the  entire  diaphysis  (Fig.  417,  J, 
and  Fig.  418, 1).  The  fistui*  which 
lead  from  the  involucrum  to  the 
surface  of  the  body  are  called  cloa- 
cse,  an  expression  which  has  jjassed 
out  of  use  at  the  present  time. 
Through  these  cloacae,  or,  better, 
tistulse,  the  pus  escapes  from  the 
cavity  containing  the  sequestrum 
(Fig.  417,  «,  and  Fig.  418,  a). 
Large  defects  develop  especially  in 
those  parts  of  the  involucrum  where 
the  periosteum  has  perished  in  consequence  of  suppuration  or  a  trau- 
matism. In  cases  of  central  neci'osis — i.  e.,  necrosis  in  the  interior  of  a 
bone — the  innermost  layers  of  the  involucrum  are,  of  course,  formed 
from  portions  of  the  old  intact  bone.  But  even  in  these  central 
necroses  there  usually  occurs  a  reactive  ossifying  periostitis  with  the 
formation  of  fresh  layers  of  bone.  The  capabilities  of  regeneration 
possessed  by  bone  (a  subject  which  has  been  thoroughly  investigated 
by  Oilier)  are  in  general  very  great,  and  a  necrosis  which  involves  the 
whole  of  a  long  bone  can  be  so  completely  compensated  for  that  no 
variations  from  the  normal  will  be  noticed.  But  occasionally  the  re- 
generation is  defective,  or  may  even  be  entirely  absent  and  permit  the 
defect  to  persist.  I^ot  infrequently,  in  the  case  of  a  necrosis  involving 
the  diaphysis  of  a  long  bone  in  a  young  subject,  there  will  be  ob- 
served, in  consequence  of  the  irritation  of  the  epiphyseal  cartilages, 
an  increased  longitudinal  growth  causing  the  bone  in  question  to 
become  two  to  three  centimetres  longer  than  the  corresponding  one  on 
the  sound  side. 

Various  Kinds  of  Necrosis  Distinguished  by  their  Location  and  Extent. 
— According  to  the  situation  and  extent  of  the  necrosis  we  i-ecognise  a 
superficial,  external,  or  peripheral  necrosis  in  contradistinction  to  the 
above-mentioned  central  necrosis  occurring  in  the  interior  of  a  bone. 
We   also   recognise  a  partial    and   a   total   necrosis,   and   a  multiple 


§  106.]  NECROSIS   OF  BONE.  659 

necrosis  oecurring  in  different  portions  of  the  same  l3one  or  in  sev- 
eral bones  of  the  same  skeleton.  The  necrosis  tubulata  (Blasiiis)  -svith 
a  tubular-shaped  sequestrum  is  verj  rare  ;  the  internal  axis  of  the 
sequestrum  is  formed  of  hving  bone  substance  Tvhich  is  firmly  con- 
nected with  the  old  bone.  Consequently  we  have  to  deal  with  tubu- 
lar sequestra  in  which  there  is  a  preservation  of  the  innermost  layers 
of  bone  or  a  considerable  regeneration  of  the  latter  by  an  ossifying 
periostitis. 

Symptomatology  and  Diagnosis  of  Necrosis. — The  symptoms  caused 
by  neciosis  have  already  been  partly  described.  They  are  mainly  due 
to  the  demarcating  inflammation  and  regenerative  new  formation  of 
bone  for  casting  off  and  replacing  the  dead  portion,  which  come  more 
and  more  into  prominence  after  the  subsidence  of  the  primary  disease 
(periostitis,  osteomyelitis).  If  there  has  been  a  loss  of  substance  in 
the  overlying  soft  parts  the  dead  bone  will  be  plainly  visible ;  but  if 
the  necrotic  bone  is  covered  by  soft  parts,  and  if  the  sequestrum 
is  deeply  situated,  the  bone  will  ordinarily  be  found  to  be  evenly 
thickened  at  the  affected  point,  as  a  result  of  the  ossifying  periostitis 
(Figs.  417,  418).  The  presence  of  fistulous  tracts,  which  usually 
discharge  only  a  little  pus,  is  another  symptom  of  necrosis  of  bone.  If 
a  metal  probe  is  passed  through  these  fistulous  passages  it  will  usually 
strike  the  surface  of  the  sequestrum.  The  latter  feels  hard,  and  if 
percussed  mth  the  probe  emits  a  tympanitic  sound.  In  the  case  of 
superficial  or  total  necrosis  the  surface  of  the  sequestrum  is  smooth ;  if 
the  necrosis  is  central  the  surface  is  rough.  The  dead  bone  is  also 
recognisable  by  its  lack  of  blood,  and  by  its  white  colour  when  com- 
pared to  the  rosy  appearance  of  the  living  bone.  It  is  very  impor- 
tant, both  for  diagnosis  and  treatment,  to  determine  whether  the  se- 
questrum has  become  movable.  The  mobility  of  the  sequestrum  can 
be  ascertained  by  pressing  the  probe  firmly  against  it,  or  by  pass- 
ing two  probes  through  two  different  fistulas  down  to  the  sequestrum, 
or  finally  by  attempting  to  move  it  back  and  forth  by  means  of  a 
dressing  forceps.  Occasionally  a  sequestrum  which  has  become  entirely 
free  is  so  tightly  enclosed  that  it  is  impossible  to  demonstrate  its  mobil- 
ity. In  such  cases  the  separation  of  the  sequestrum  is  determined  by 
the  duration  of  the  disease.  Necrosis  may  be  mistaken  for  those 
central  bone  diseases  which  lead  to  enlargement  of  the  bone  with  the 
formation  of  fistulne,  such  as  central  bone  abscesses  and  tumours  of 
bone,  and  then  particularly  for  caries.  The  typical  caries,  with  few 
exceptions,  as  we  saw,  is  a  tubercular  process,  and  is  very  often  com- 
bined with  necrosis.  The  tubercular  sequestra  usually  contain  cheesy 
tissue  and  have  a  soft  feeling,  while  the  sequestra  of  ordinary  necrosis 


QQQ  INJURIES  AND   SURGICAL  DISEASES   OF   BONE. 

appear  M-hite  and  hard,  like  normal  bone.  The  pus  in  necrosis  is  scanty 
and  more  mucoid,  but  in  caries  it  is  a  thin  hquid  mixed  with  cheesy 
masses.  The  fistulous  tracts  of  tuberculosis  generally  have  a  pale, 
lardaceous  appearance,  and  if  a  probe  is  introduced  through  them  it 
strikes  against  soft,  crumbling  bone  ;  while  in  necrosis  the  granulations 
usually  have  a  vigorous,  healthy  appearance  and  bleed  easily,  and  the 
sei|uestrum  when  touched  by  the  probe  feels  hard.  Furthermore,  the 
development  of  the  two  diseases  is  different.  The  tubercular  caries 
begins  gradually,  and  mainly  affects  the  epiphyses  and  the  spongy 
bones,  while  the  typical  necrosis  ordinarily  develops  after  acute  or  sub- 
acute inflammation  of  bone,  especially  the  long,  hollow  bones  (femur, 
tibia,  humerus). 

Treatment  of  Necrosis. — The  treatment  of  necrosis  before  the  seques- 
trum has  separated  is  purely  symptomatic,  and  consists  mainly  in  keep- 
ing the  fistulse  clean.  When  the  sequestrum  has  become  completely 
free  it  must  be  removed  by  operation,  if  it  has  not  already  been  spon- 
taneously cast  off  or  out.  Even  large,  deeply  located  sequestra  can 
work  their  way  outwards  through  the  cloacae  and  come  to  lie  beneath 
the  skin,  which  they  then  gradually  penetrate.  I  extracted  simply 
with  the  fingers,  in  the  case  of  a  twelve-year-old  boy,  a  large,  com- 
pletely separated  sequestrum  consisting  of  the  entire  thickness  of  the 
femur.  During  many  months  it  had  projected  several  centimetres 
from  the  soft  parts,  and  no  one  had  dared  remove  it.  As  a  rule,  only 
those  sequestra  which  are  completely  free  should  be  removed,  but 
there  are  a  few  exceptions  to  this.  In  the  case  of  j^hosphorus  necrosis, 
for  instance,  the  foul  suppuration  compels  us  to  adopt  operative  meas- 
ures before  the  sequestrum  has  become  completely  separated,  and  early 
resection — i.  e.,  early  removal  of  the  primary  focus  of  disease — should 
be  undertaken  to  shorten  the  process  and  to  prevent  it  from  extending 
further.  If  the  disease  is  left  to  itself,  the  entire  lower  jaw  perishes, 
according  to  Hackel,  in  seventy -nine  per  cent,  of  the  cases.  In  ordinary 
necrosis  we  must  wait  for  the  separation  of  the  sequestrum  to  become 
complete,  for  the  reason  that  the  loss  of  substance  will  have  been 
replaced  by  a  new  formation  of  bone,  and  that  if  we  operate  before  the 
separation  is  complete  we  are  liable  to  remove  too  much  of  the  healthy 
bone,  or  possibly  too  little  of  that  which  is  dead.  In  doubtful  cases, 
where  the  mobility  of  the  sequestrum  cannot  be  determined,  the  length 
of  time  the  process  has  lasted  must  be  taken  into  consideration  in 
deciding  whether  or  not  operative  removal  of  the  sequestrum  should 
be  undertaken.  On  the  other  hand,  when  the  necrosis  is  extensive, 
though  the  sequestrum  be  free,  the  operation  should  be  postponed  if 
the  new  formation  of  bone  is  too  scanty. 


106.] 


NECROSIS   OF  BONE. 


661 


The  Operative  Removal  of  the  Sec[uestrum  (Sequestrotomy). — If  the 
necrosis  is  not  encapsulated,  the  fistulse  are  simply  enlarged  to  the 
necessary  amount  with  the  knife  and  the  sequestrum  extracted  with 
suitable  forceps,  such  as  a  dressing  forceps.  If  the  sequestrum  is 
encapsulated  by  an  involu- 
crum,  the  latter  must  be 
opened  with  the  hammer  and 
chisel  after  freely  dividing 
the  soft  parts  and  elevating 
the  periosteum.  An  Esmarch 
bandage  should  be  used  for 
the  extremities.  After  ex- 
traction of  the  sequestrum 
the  cavity  in  the  bone  should 
be  thoroughly  scraped  out, 
and  then  either  packed  with 
iodoform  gauze,  or  the  wound 
in  the  soft  parts  closed  almost 
entirely  by  sutures,  after  pro- 
viding for  drainage.  If  the 
wound  is  left  to  granulate, 
the  skinning-over  process  can 
be  hastened  later  on  by 
the  transplantation  of  skin. 
Schede's  method  of  obtain- 
ing healing  under  an  aseptic 
blood-clot  (see  page  109)  is 
also  good — i.  e.,  the  wound 
in  the  soft  parts  is  closed 
by  sutures  without  drainage, 
though  I  leave  one  angle  open 
as  a  means  of  escape  for  any 

surplus  accumulation  of  fluid.  To  prevent  recurrences  and  to  obtain 
speedy  recovery,  the  involucrum  should  be  removed,  as  Kiedel  rightly 
says,  until  only  a  wall  of  cortex  remains  in  the  form  of  a  flat  gutter. 
If  the  operation  has  been  performed  with  an  Esmarch  bandage,  anti- 
septic dressings  exerting  pressure  should  be  applied,  and  the  extremity 
elevated,  before  the  rubber  tourniquet  is  removed ;  the  limb  should 
then  be  kept  elevated  for  the  next  twelve  to  twenty-four  hours.  It  is 
very  important  that  the  extremity  which  has  been  operated  upon 
should  be  immobilised  as  much  as  possible  by  a  splint.  If  fistulte 
persist,  they  must  be  thoroughly  scraped  out,  and  the  sequestrotomy. 


Fig.  419. — Incision  b,  a, 
c,  d,  for  osteoplastic 
sequestrotomy. 


Fig.  420.— Eeflection  of 
a  flap  of  skin,  perios- 
teum, and  bone  in  os- 
teoplastic sequestrot- 
omy. 


662  INJURIES  AND  SURGICAL   DISEASES   OF   BONE. 

when  necessary,  repeated  for  the  extraction  of  any  other  sequestra 
%yhich  may  be  present.  Sequestrotoniy  is  not  at  all  a  dangerous  ojiera- 
tion  if  perfoi'med  with  antiseptic  precautions. 

Liicke  and  Bier  haye  recommended  a  new  method  for  sequestrot- 
omy  which  is  called  osteoplastic  necrotomy  (Fig.  419).  In  the  first 
place,  the  incisions  a  c,  a  h,  and  e  d  are  made  through  the  soft  parts, 
then  the  bone,  wliich  in  Fig.  419  is  the  tibia,  is  cut  half  through 
transyerselj  with  a  keyhole  saw  and  diyided  with  the  chisel  in  the  line 
of  the  longitudinal  incision.  By  depressing  the  handle  of  the  chisel 
the  skin-periosteal-bone  flap  thus  fashioned  is  broken  through  along 
the  hue  where  it  still  remains  joined  to  the  rest  of  the  cortex,  and  is 
turned  back  like  the  lid  of  a  box,  exposing  the  cayity  containing  the 
sequestrum  (see  Fig.  419).  After  remoying  the  sequestrum  and  scrap- 
ing out  and  disinfecting  the  cavity,  the  coyer  is  replaced,  and  the 
wound  in  the  soft  parts  closed  immediately  or  by  secondary  sutures 
applied  after  the  wound  has  first  been  packed.  Becoyery  usually  takes 
place  with  slight  suppuration.  In  cases  where  after  removal  of  the 
sequestrum  a  defect  in  the  bone  has  resulted  in  consequence  of  incom- 
plete formation  of  the  involucrum,  the  defect  is  treated  by  the  methods 
described  on  pages  607  and  029. 

§  107.  Spontaneous  (Inflanimatory)  Separations  of  the  Epiphyses. — 
The  spontaneous  (inflammatory)  separations  of  the  epiphyses  which 
occur  in  the  bones  of  young  subjects  at  the  cartilaginous  junctions 
yvith  the  diaphyses  have  already  been  discussed  under  the  subject  of 
Suppurative  Periostitis  and  Osteomyelitis.  As  a  matter  of  fact,  the 
spontaneous  separation  of  an  epiphysis  from  the  bone  is  almost  always 
secondary  to  suppurative  inflammation  of  the  periosteum,  the  marrow 
of  the  bone,  or  the  joint.  But  occasionally  the  epiphyseal  separation 
is  due  to  primary  inflammation  at  the  cartilaginous  symphysis,  as,  for 
example,  is  the  case  in  the  osteochondritis  luetica  occurring  in  the 
course  of  syphilis.  Multiple  epiphyseal  separations  affecting  several 
bones  have  been  obseiwed  in  py?emia.  The  non-suppurative-spon- 
taneous  epiphyseal  separation  is  yery  rare,  and  when  it  does  take  place 
may  be  due,  according  to  Poupart,  Petit,  and  Yolkmann,  to  a  hsemor- 
I'hagic  malacia  of  the  epiphyseal  cartilages  occurring  in  scurvy.  The 
osteochondritis  dissecans  described  by  Konig,  the  nature  of  which  is 
obscure,  also  sometimes  leads  to  complete  separation,  for  example, 
of  the  head  of  the  femur  from  its  neck,  without  any  traumatism 
having  been  received,  and  even  occurs  in  people  from  thirty  to  forty 
years  of  age. 

According  to  Yolkmann,  the  typical  spontaneous  separation  of 
the  epiphysis  is  generally  observed  before  the  fifteenth  year,  and  no 


§  108.]  RHACHITIS.  663 

case  has  been  recorded  where  it  happened  later  than  the  twentieth 
year.  It  is  well  known  that  the  cartilage  between  the  epiphyses  and 
diaphyses  persists  till  about  the  twentieth  to  twenty-second  to  twenty- 
fourth  year  of  life,  the  epiphyses  joining  with  the  diaphyses  some- 
what earlier  in  women  than  in  men.  Separation  of  the  epiphysis  is 
most  common  at  the  lower  end  of  the  femur  and  the  upper  end  of  the 
tibia. 

Traumatic  separations  of  the  epiphysis  are  described  on  pages  597 
and  612. 

The  symptoms  of  epiphyseal  separation  are  in  the  main  those  of  a 
fracture,  and  repair  takes  place  in  precisely  the  same  way.  "We  have 
discussed  on  page  612  the  occurrence  of  disturbances  of  growth  after 
hony  consolidation  of  the  epiphyseal  line.  It  need  only  be  briefly 
stated  here  that  in  two  cases  of  suppurative  separation  of  the  upper 
epiphysis  of  the  tibia  in  comparatively  young  children,  Blasius  and 
Yolkmann  were  able  subsequently  to  demonstrate  no  shortening  after 
the  growth  of  the  body  had  been  completed. 

The  treatment  of  separations  of  the  epiphyses  is  conducted  accord- 
ing to  the  rules  which  govern  the  treatment  of  simple  and  compound 
fractures,  and  is  the  same  as  that  for  traumatic  separations,  which  was 
^iven  in  §  101. 

§  108.  Rhacliitis. — Hhachitis  (f rom  -^a^^t?,  the  spine)  is  a  general  dis- 
turbance of  nutrition  which  occurs  in  early  childhood,  and  anatomically 
is  characterised  mainly  by  the  formation  of  bone  which  is  deficient  in 
lime,  and  by  an  increased  absorption  of  bone.  Therefore  the  bones 
affected  by  rickets  are  abnormally  soft  and  have  a  tendency  to  bend, 
to  suffer  infractions;  and  the  epiphyseal  cartilages  are  remarkably 
thick — a  peculiarity  which  has  given  the  disease  the  name  of  dojpjpelte 
GUecler  (double  limbs).  Rhachitis  is  a  disease  affecting  the  develop- 
ment of  bone,  and  a  true  disease  of  childhood,  most  commonly  begin- 
ning in  the  first  or  second  year  of  life,  very  rarely  after  the  fifth  or 
sixth.  According  to  Schwartz,  pronounced  rickets  is  often  observed 
in  infants,  and  the  investigations  of  Kassowitz  show  that  it  frequently 
begins  during  the  latter  months  of  foetal  life,  in  consequence  of  the 
transmission  of  morbid  stimuli,  or  as  a  result  of  deficient  absorption  of 
lime  from  the  maternal  circulation,  and  then  during  the  months  imme- 
diately following  birth  the  symptoms  of  the  affection  become  more  and 
more  marked.  Hereditary  syphilis  is,  in  my  opinion,  a  predisposing 
factor  in  the  etiology  of  rhachitis.  In  the  Yienna  obstetrical  chnic, 
among  five  hundred  children,  Schwartz  found  80.6  per  cent,  to  be 
rhachitic,  and  the  great  majority  of  the  mothers  of  these  rhachitic 
children  had  lived  under  improper  dietetic  and  hygienic  conditions, 


QCA 


INJURIES  AND  SURGICAL   DISEASES  OP   BONE. 


and  during  their  pregnancy  had  done  hard  woi'k.  Marchand,  Kauf- 
mann,  and  others  claim  that  a  great  many  of  the  cases  of  so-called 
foetal  rhachitis  are  not  real  rickets.  Marchand  has  accordingly  pro- 
posed for  these  cases  the  name  micromelia 
chondromalacia,  and  Kaufmann  chondro- 
dystrophia  fcetalis.  The  foetal  cartilage  is 
the  site  of  the  disease  or  malformation,  and 
depending  upon  the  condition  of  the  same 
Kaufmann  distinguishes  (1)  chondrodys- 
trophia  malacia,  (2)  chondrodystrophia  hy- 
poplastica,  and  (3)  chondrodystrophia  hy- 
perplastica.  The  disease  is  sometimes  he- 
reditary. Infantile  rhachitis  is  sometimes 
combined,  particularl}'  in  the  first  years  of 
life,  with  symptoms  of  scurvy,  viz.,  haem- 
orrhages in  the  periosteum,  the  gums,  the 
skin,  the  intestine,  the  bladder,  mucous 
membranes,  ventricles  of  the  vein,  etc. 
This  affection  (Barlow's  or  Moller's  disease) 
is  probably  a  specific  cachexia. 

Anatomical  Changes  in   Rhachitis. — The 

anatomical  changes  in  rickets  have  recently 
been  studied  by  Virchow,  Kassowitz,  Baginsky^ 
and  others.  Kassowitz  ascribes  all  the  mani- 
festations of  rhachitis  to  chronic  inflammatoi-y 
changes  at  the  boundary  line  between  the  foetal 
and  infant  bone — i.  e.,  to  an  abnormally  in- 
creased vascularisation  of  the  tissues  which  go 
to  form  bone.  As  a  result  of  this  hypergemia^ 
and  the  numerous  chiefly  new-formed  vessels 
at  tlie  epiphyses  in  the  periosteuna  and  medulla, 
there  occurs  a  growth  of  the  epiphyseal  car- 
tilages, a  diminished  deposit  of  lime  salts,  and 
an  increased  absorption  of  the  fully  formed 
bone.  The  bone  undergoes  a  lacunar  absorp- 
tion (Fig.  401),  osteoclasts  being  present,  and, 
as  I  have  stated  before,  is  probably  dissolved 
by  carbonic  acid.  Rhachitic  bone  is  poor  in 
lime,  and  the  newly  formed  bone  remains  for 
a  long  time  in  the  uncalcified  state.     Not  till 


Fig.  421. — Ehachitis.  Longitudi- 
nal section  through  the  upper 
epiphysis  of  the  tibia  near  the 
boundary  of  ossification  :  a,  zone 
of  the  proliferating  columns  of 
cartilage ;  b,  vascular  medullary 
spaces  in  the  cartilage ;  c,  calci- 
fied cartilaginous  tissue;  cZ,  os- 
teoid uncalcitied  or  only  slight- 
ly calcified  tissue  with  remnants 
of  cartilaginous  tissue;  «,  fully 
formed  bone. 


the  rhachitis  has  run  its  course  does  the  ground 
substance  of  the  bone  become  completely  calcified,  and  then  usually  to  an 
extreme  degree,  so  that  the  affected  bone  appears  thickened  and  very  hard 
— sclerosed.  The  changes  at  the  epiphyses  are  very  characteristic.  Under 
normal  conditions  the  epiphysis  is  defined  by  a  plain  white  line,  cartilage 


108.] 


RHACHITIS. 


665 


and  bone  being-  sharply  differentiated  from  one  ^lother.  But  in  rhachitis 
this  sharply  defined  linear  boundary  is  absent,  and  the  different  tissues,  the 
cartilage,  bone,  and  medulla,  appear  as  though  blended  together  without  any 
system  (Fig.  431).  The  cartilaginous  epiphyseal  line  is  broadened  and  irregu- 
lar, the  boundary  between  cartilage,  bone,  and  medullary  tissue  is  not  well 
marked,  and  the  zone  of  calcification  at  the  points  of  ossification  is  absent  or 
deficient.  The  most  important  factors  in  the  process  are  always  the  insuf- 
ficient deposit  of  lime  salts  and  the  increased  absorption  of  the  bone  already 
present.  Baginsky  states  that  rhachitic  bone  has  lost  more  than  three 
fourths  of  the  lime  it  contains.  Rhachitic  bones  are  so  soft  that  they  can 
easily  be  cut  with  a  knife,  and,  in  consequence  of  this  softness,  deformities 
of  the  skeleton  occur.  In  older  children 
the  changes  in  the  thorax,  the  vertebrae, 
and  extremities  are  more  prominent  than 
those  in  the  skull.     Bow-shaped  curves 


Fig.  422.— Ehachitic  deformities  of  the  leg. 


Fig.  42-3. — Bilateral  rhachitic  genu  valgum  in 
a  boy  five  and  a  half  years  old  cured  by 
osteotomy  of  the  femur  and  tibia. 


develop  in  the  bones  of  the  extremities,  or,  more  commonly,  angiilar  deformi- 
ties at  the  ends  of  the  diaphyses  (Fig.  422)  with  thickening  of  the  epiphyses. 
The  joints  are  loose,  abnormally  movable,  and  painful.  At  the  knee  joint, 
for  instance,  there  is  very  often  a  considerable  abduction  or  adduction  and 
rotation  of  the  leg  in  consequence  of  the  relaxation  of  the  ligaments  of  the 
joint  and  the  rhachitic  curvature  which  exists  in  the  tibia  and  femur  (genu 
valgum  and  genu  varum  rhachiticum).  At  the  hip  joint  the  rhachitic  bend- 
ing of  the  neck  of  the  femur  is  to  be  noted.  In  the  foot  the  so-called  "  flat 
foot "  develops,  etc.  This  relaxation  of  the  joints  and  softness  of  the  bones 
are  the  reasons  why  rhachitic  children  take  so  long  to  stand  and  walk,  and 
why  they  lose  their  ability  to  perform  these  acts  in  recurrent  rhachitis  or 


^66  INJURIES  AND   SURGICAL  DISEASES  OF   BONE. 

rliachitis  of  late  development.  The  pelvic  walls  sink  inward,  causing  the 
■cavity  to  become  conti'acted,  the  promontory  of  the  sacrum  projects  down- 
wards and  forwards,  the  acetabular  region  is  pushed  inwards,  the  symphysis 
forwards.  Curvatures  develop  in  the  vertebra-  (scoliosis,  kyphosis),  and  the 
thorax,  particularly  at  the  points  where  the  ribs  join  the  costal  cartilages, 
becomes  depressed,  so  that  in  severe  cases  the  sternum  is  jDushed  forwards 
{the  so-called  "chicken  breast,"  or  pectus  carinatum).  In  the  skull,  espe- 
cially in  the  occipital  region,  the  bones  remain  for  a  very  long  time  soft  and 
yielding  to  pressure,  and,  as  a  result  of  the  loss  of  bone  substance,  some  por- 
tions may  again  become  membranous  (cranio-tabes  rhachitica).  The  cutting 
-of  the  teeth  is  delayed,  and  after  the  disease  has  been  cured  they  often  come 
tlu'ough  precipitately.  The  longitudinal  growth  and  body  weight  are  less 
than  they  normally  should  be.  Bouchat  states  that  rhachitic  children  only 
^row  about  two  to  three  centimetres  in  a  year,  while  the  average  longitudi- 
nal growth  in  health  amounts  to  about  seven  to  eight  centimetres. 

Among  anomalies  of  internal  organs  are  to  be  mentioned  disturbances  of 
the  central  nervous  system  and  of  the  circulatory  and  digestive  organs,  such 
as,  for  example,  hypertrophy  or  sclerosis  of  the  brain,  and  chronic  hydro- 
cephalus. The  spasm  of  the  glottis,  which  is  so  common  in  rhachitic  chil- 
dren, is  probably  caused  by  a  general  or  a  reflex  anaemia.  Disturbances  of 
digestion  (dyspepsia,  diarrhoea  alternating  with  constipation),  chronic  bron- 
chitis, lobular  pneumonia,  etc.,  are  very  common.  The  liver  is  very  often 
decreased  in  size ;  the  spleen,  on  the  other  hand,  is  usually  but  not  always 
enlarged,  and  sometimes  attains  enormous  dimensions.  The  skin,  mucous 
membranes,  lymph  glands,  etc.,  often  show  the  same  disturbances  of  nutri- 
tion as  in  scrofula  (see  page  433).  In  the  form  of  rhachitis  appearing  some- 
what later  in  life  (rhachitis  tarda),  Levrat  (Lyon)  very  often  observed  goitre. 

Analyses  of  the  urine  show,  according  to  Baginsky,  that  (1)  a  healthy 
child  retains  more  nitrogen  in  its  system  than  a  rhachitic  one,  and  excretes 
phosphoric  acid  more  freely  in  the  urine  ;  (2)  that  under  the  influence  of 
dyspeptic  conditions  the  rhachitic  child  excretes  nitrogen  in  the  urine  more 
readily  than  the  healthy  child,  and  retains  phosphoric  acid ;  (3)  that  no  dif- 
ference can  be  made  out  between  healthy  and  rhachitic  children  as  regards 
the  excretion  in  the  urine  of  lime  and  magnesium  ;  (4)  that  the  relative 
amount  of  chlorine  excreted  in  the  urine  of  healthy  children  is  greater  than 
in  that  of  rhachitic  children.  As  I'egards  the  excretion  of  phosphorus  or  phos- 
phoric acid  in  the  urine  of  rhachitic  children,  the  statements  of  authorities 
vary  greatly ;  but  as  a  general  thing  the  majority  of  German  authorities 
declare  that  there  is  a  diminution  of  the  phosphoric  acid  in  the  urine  (hj^po- 
phosphouria)  in  rickets ;  while  the  majority  of  French  authoi'ities  maintain 
that  there  is  an  increase  (hyperphosphouria). 

The  analysis  of  the  ash  of  the  faeces  shows  that  more  lime  is  excreted  in 
the  stools  of  rhachitic  children  (to  one  kilogramme  of  body  weight)  than  is 
normally  the  case,  and  that  the  excretion  of  phosphoric  acid,  as  compared 
with  that  in  health,  is  not  increased.  The  careful  investigations  of  Babeau 
«how  that  an  abnormal  amount  of  lime  is  excreted  only  in  the  developmental 
period  of  rickets  ;  this  occurs  through  the  urine  in  case  of  imperfect  assimila- 
tion of  the  lime  in  the  bone,  or  through  the  faeces  in  consequence  of  insuflS.- 
<;ient  absorption  of  lime  by  the  intestine. 


§  108.]  RHACHITIS.  (^Q^ 

The  Etiology  of  RhacMtis. — The  cause  of  rickets — wHcli  we  have 
learned  to  recognise  as  a  general  disturbance  of  nutrition  in  children, 
mainly  localised  in  the  bony  system — has  been  made  the  subject  of 
much  experimental  investigation.  The  majority  of  the  authorities 
ascribe  the  cause  of  rhachitis  to  malnutrition.  As  a  matter  of  fact,  we 
know  that  a  proper  supply  of  the  salts  of  the  alkalies  and  of  the  earthy 
salts  is  of  the  greatest  importance  for  the  nutrition  of  all  the  tissues. 
Chossat  and  others  have  demonstrated  by  experiments  on  young  grow- 
ing animals  that  by  feeding  them  with  food  deficient  in  lime,  young 
hirds  and  dogs,  for  example,  show  changes  which  are  analogous  to 
those  in  rhachitis  ;  but  the  diminished  absorption  of  lime  should  not  be 
so  much  emphasized  as  the  general  insufficient  nourishment  and  care 
of  the  child.  Baginsky,  whose  careful  investigations  include  627  cases 
of  rickets  (347  boys  and  280  girls),  also  states  that  the  disease  is  a  result 
of  unfavourable  conditions  of  life,  especially  deficient  nourishment,  bad 
dwellings,  etc.  Rhachitis  is,  in  fact,  a  disease  of  the  poor,  particularly 
in  large  cities,  and  occurs  less  often  in  the  country,  as  Morgan  and 
Baxter  have  recently  proved  by  extensive  statistics.  Billroth  and  Wini- 
warter maintain  that  in  Yienna  about  eighty  per  cent,  of  the  children 
of  the  poorer  classes  show  symptoms  of  rickets.  Children  who  are 
brought  up  by  bad  artificial  feeding  without  being  jiursed  at  the  breast, 
and  who  have  disorders  of  digestion,  are  particularly  apt  to  be  affected 
with  rickets.  According  to  E..  L.  Lee,  preceding  respiratory  disturb- 
ances due  to  bronchitis,  pneumonia,  whooping-cough,  etc.,  are  also  of 
great  etiological  importance.  Furthermore,  we  saw  on  page  663  that 
the  syphilitic  poison,  and  possibly  also  other  hsematogenous  dyscrasise, 
excite  changes  at  the  epiphyseal  junctions  which  are  similar  to  those  of 
true  rhachitis ;  and  doubtless  rickety  children  suffer  from  hereditary 
syphihs  more  often  than  is  generally  supposed.  Rickets  is  perhaps 
mainly  an  infectious  disease ;  the  poisons  prevent  a  sufficient  and  per- 
manent union  of  the  lime  salts  with  the  tissue  from  which  bone  is 
formed. 

The  Course  of  Rhachitis  is  for  the  most  part  chronic,  more  rarely 
acute,  and  the  earlier  the  rhachitis  occurs  the  more  rapid,  as  a  general 
thing,  is  its  course.  Thus  the  rare  cases  of  congenital  rickets  run  a 
very  rapid  course ;  and  of  the  children  affected  by  the  disease  during 
the  months  immediately  following  birth,  a  large  part  perish  from  in- 
creasing inanition  due  to  unfavourable  hygienic  conditions.  But  if 
the  causative  factors  are  removed,  and  the  children  properly  fed  and 
their  surroundings  improved,  the  disease  usually  disappears  rapidly — 
in  the  milder  cases  within  five  to  six  months,  and  in  the  more  severe 
ones  within  two  to  three  years.     Occasionally  the  disease  drags  on  till 


668  INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 

the  fifth  or  sixth  year ;  cases  lasting  longer  than  this  are  very  rare.  In 
the  cases  of  acute  rhachitis  there  are  sometimes  complicating  disturb- 
ances of  nutrition,  particularly  scurvy,  which  may  occur  simultaneously 
with  the  rickets  (Th.  Smith,  Barlow,  etc.). 

The  Diagnosis  of  Rhachitis,  as  a  rule,  is  very  easy,  for  the  reason  that  the 
above-described  anatomical  changes  in  the  skeleton  are  pathognoraonic.  It 
should  be  a  rule,  in  making  an  examination,  to  undress  completely  all  chil- 
dren sutfering  from  chronic  disease. 

The  Prognosis,  if  proper  treatment  is  adopted,  is  favourable,  as  we  have 
said  before.  But  if  the  unfavourable  conditions  continue,  a  large  proportion 
of  rhachitic  children  perish  from  diseases  of  the  intestinal  tract,  of  the  respira- 
tory oi'gans,  from  hydrocephalus,  general  inanition,  etc. 

The  Treatment  of  Rhachitis  consists,  in  the  first  place,  in  the  ad- 
ministration of  proper  food  to  the  child,  and  in  doing  away  as  soon  as 
possible  with  all  unfavourable  hygienic  conditions.  Inasmuch  as  recent 
investisations  show  that  rhachitis  is  of  such  conmion  occurrence  in 
young  infants,  they  must  always  be  carefully  examined  for  its  presence, 
and  in  cases  where  the  disease  is  found  the  proper  treatment  must  be 
begun  early.  The  best  food  for  suckling  children  is  mothers'  milk  or 
good  cows'  milk  sterilised  by  Soxhlet's  ajjparatus.  Nursing  the  child 
longer  than  the  first  year  of  its  life,  Baginsky  states,  is  just  as  apt  to 
cause  rickets  as  is  the  administration  at  too  early  a  period  of  starchy  or 
indigestible  food.  All  disorders  of  digestion  and  other  complications 
in  rhachitic  children  should  be  carefully  treated  according  to  the  gen- 
eral rules  which  apply  to  them.  Internally,  cod-liver  oil,  iron,  lime, 
phosphorus,  arsenic,  and  pyrogallic  acid  have  been  recommended  for 
rhachitis,  but  in  their  administration  the  state  of  the  digestive  organs 
must  be  taken  into  consideration.  Cod-liver  oil,  which  may  be  com- 
bined with  extract  of  malt,  is  useful  for  children  who  are  not  fat,  espe- 
cially in  winter.  Lime  is  given  in  the  form  of  liquor  calcis  added  to 
milk,  or  in  a  mixture  made  of  carbonate  and  phosphate  of  calcium  with 
ferri  oxyd.  sacch.  (ferri  carb.  sacch.),  equal  parts  of  each,  enough  to 
cover  the  point  of  a  knife,  three  times  a  day.  On  account  of  its  osteo- 
plastic action  the  administration  of  phosphorus  has  recently  been 
recommended  for  rhachitis  by  Wegner  and  Kassowitz.  It  is  givea 
(1  milligramme  jy;'o  die)  in  cod-liver  oil  (0.01  gramme  phosphor.,  1000. 
cubic  centimetres  ol.  morrhuse,  one  to  two  teaspoonfuls  a  day),  or  in 
pill  form  with  oil  of  phosphorus  and  some  indifferent  powder  enclosed 
in  gelatine  capsules.  Maas  and  others  maintain  that  arsenic  and  pyro- 
gallic acid  have  also  an  osteoplastic  action  like  phosphorus.  Three  per 
cent,  brine  baths,  sea  baths,  health  resorts  situated  on  high  land,  and 
proper  climate  have  as  valuable  an  influence  upon  rickets  as  they  have 


§109.]  .  OSTEOMALACIA.  669 

upon  scrofula  (see  page  43-4).  To  prevent  as  far  as  possible  the  curva- 
tures and  angular  deformities  which  may  occur  in  the  extremities,  for 
example,  rhachitic  children  should  not  be  encouraged  to  stand  and  walk 
at  too  early  a  period.  Braces  and  similar  apparatus  should  be  used  to 
support  the  lower  extremities,  and  the  application  of  light  water-glass 
or  starch  dressings  is  also  advantageous,  j^iter  the  rhachitis  has  sub- 
sided, the  bopy  deformities,  particularly  those  in  the  leg,  frequently  have 
to  be  corrected.  Rhachitic  curvatures  often  straighten  out  spontane- 
ously, and  hence  one  should  not  operate  too  soon.  Up  to  the  fifth  year 
they  can  usually  be  treated  expectantly  ;  after  that  they  generally  have 
to  be  coi-rected  by  osteoclasis  (see  page  91),  or,  better,  by  osteotomy.  To 
perform  osteotomy,  the  proper  incision  is  made  through  the  skin,  and 
through  this  the  bone  is  divided  mth  the  hammer  and  chisel,  with  the 
exception  of  a  small  portion  of  the  cortex,  which  is  then  usually  broken 
by  hand.  The  wound  is  not  sutured,  and  after  covering  it  with  an 
antiseptic  protective  dressing  a  plaster- of -Paris  splint  is  immediately 
applied.  If  the  operation  is  carried  out  with  antiseptic  precautions  it 
is  entirely  devoid  of  danger.  Macewen's  osteotomy  at  the  lower  end 
of  the  diaphysis  of  the  femur  is  also  very  appropriate  in  cases  of  genu 
valgum  rhachiticum.  Tenotomy  of  the  tendo  Achillis  must  sometimes 
be  added  when  the  curvature  of  the  tibia  is  convex  anteriorly.  But 
frequently  braces  will  be  suflacient  to  overcome  deformity,  the  bones 
gradually  becoming  straight  of  their  own  accord.  I  must  refer  the 
reader  to  the  Regional  Surgery  for  the  particulars  of  the  treatment  for 
the  various  sequelse  of  rhachitis  in  the  different  portions  of  the  body, 
such  as  the  vertebrae,  the  extremities,  etc. 

§  109.  Osteomalacia. — By  osteomalacia  we  understand  a  peculiar 
softening  and  absorption  of  bone  substance  which  is  observed  most 
commonly  in^women  during  pregnancy  and  the  puerperium,  less  often 
in  men,  and  in  women  who  are  not  pregnant.  The  disease  not  infre- 
quently occurs  in  pregnant  and  milch  cows.  In  osteomalacia  the  nor- 
mal, strong  bones  of  adults  become  soft,  while  in  rhachitis,  on  the  other 
hand,  we  have  to  deal  with  a  disease  of  development  affecting  young 
bone,  in  consequence  of  which  the  latter  remain  soft  and  do  not  be- 
come firm. 

Anatomical  Changes  in  Osteomalacia.— The  puerperal  form  of  osteoma- 
lacia probably  always  begins  in  the  pelvis,  and  either  remains  limited  to  the 
latter  or  attacks  other  bones,  and  may  even  involve  most  of  the  skeleton, 
particularly  if  the  woman  passes  through  several  pregnancies  after  the 
appearance  of  the  disease.  The  non-puerperal  form  begins  most  commonly 
in  the  vertebrae  and  thorax,  and  then  extends  to  the  extremities,  and  finally 
to  the  bones  of  the  head.  The  softening,  the  absorption  of  bone  substance 
(Fig.  424),  is  an  halisteresis — i.  e.,  the  lime  salts  are  first  dissolved,  but  the 


670 


INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 


decalcified  ground  substance  persists  a  little  while  longer,  then  it  also  gradu- 
ally disintegrates,  and  is  finally  absorbed.  The  absorption  of  the  lime  salts 
always  begins  in  the  periphery  of  the  bone  and  advances  steadily  towards 
the  centre.  In  this  manner  a  considerable  loss  of  bone  may  be  brought 
about  and  the  cortex  of  the  long  bones  may  become  as  thin  as  paper,  or  the 
diseased  bone  may  even  entirely  disappear,  leaving  only  the  periosteum  and 
medulla  to  persist  as  an  elastic  tube.  Morand  observed  a  very  pronounced 
degree  of  osteomalacia  in  a  woman  who  possessed  in  the  place  of  most  of 
her  bones  only  membranous  cylinders  or  very  thin  tubes  of  bone.  In  the 
milder  cases,  which  recover  quickly,  the  decalcified  bone  substance  can  be 
very  rapidly  changed  to  normal  bone  by  a  fresh  deposit  of  the  salts  of  lime. 
As  long  as  the  disease  is  advancing  tlie  medulla  is  usually  very  richly  sup- 
plied with  blood,  contains  numerous  ha^morrhagic  foci  scattered  through  it, 


Fig.  424. — Osteomalacia  (pelvis).    Trabeculse  of  decalcified  bone  with  remnants  of  calcified  bone. 
The  enlarged  medullary  spaces  (J/)  have  arisen  from  absorption  of  the  trabeculse.     x  75. 


has  an  abundance  of  cells,  and  is  jioor  in  fat.  In  rare  instances  of  osteoma- 
lacic softening  of  bone  there  have  been  noted  multiple  cj^stic  formations 
with  tumour-like  enlargement  of  the  softened  portions  of  bone  (Albertin). 
There  are,  moreover,  cases  which  present  the  clinical  picture  of  osteoma- 
lacia, and  anatomically  are  due  to  the  development  of  multiple  true  tumours, 
especially  sarcomata  (Recklinghausen).  As  a  result  of  the  softening  of  the 
bones  there  of  course  arise  con-esponding  curved  or  angular  deformities  and 
fractures.  Changes  of  shape  in  the  osteomalacic  pelvis  are  particularly  com- 
mon. Recklinghausen  and  Rehn  have  recently  described  an  infantile  osteo- 
malacia, but  this  is  probably  in  the  main  a  severe  rhachitis. 

The  Etiology  of  Osteomalacia. — The  precise  cause  of  osteomalacia  is 
still  but  little  understood,  though  various  theories  have  been  advanced. 
"We  only  know  that  it  occurs  chiefly  in  pregnant  or  nursing  women 
and  animals,  and  is  common  in  certain  regions  which  in  Germany  lie 
along  the  Rhine,  while  other  places,  like  the  valley  of  the  Oder,  appear 
to  be  free  from  it.  Damp,  unhealthy  dwelHngs,  malaria,  ansemia,  and 
other  constitutional  anomalies  connected  with  disturbances  of  nutrition, 
are  said  to  be  of  importance.     Cohnheim  maintains  that  osteomalacia, 


§  109.]  •  OSTEOMALACIA.  6Y1 

like  rhachitis,  is  a  disturbance  of  nutrition,  and  lie  believes  tliat  the 
maternal  organism  during  pregnancy  and  the  nursing  period  contains 
too  little  lime,  because  a  very  large  amount  of  lime  salts  is  necessary 
for  the  development  of  the  foetal  skeleton  as  well  as  for  the  milk.  For 
this  reason  only  osteoid  tissue,  which  is  deficient  or  entirely  lacking  in 
lime,  is  formed  in  the  maternal  organism.  Consequently,  according  to^ 
Cohnheim's  theory,  the  uncalcified  or  deficiently  calcified  bone  tissue 
is  not  decalcified  old  bone  tissue,  but  new-formed  osteoid  tissue.  I 
believe,  however,  that  the  old  idea  is  correct,  viz.,  that  the  bone  tissue- 
which  is  poor  in  lime  or  in  which  the  hme  is  absent  is  the  decalcified 
ground  substance  of  the  old  bone.  It  is  natural  that  the  cause  for  the 
decalcification  in  this  condition  should  also  be  ascribed  to  an  acid  such 
as  lactic  acid,  or,  more  correctly,  carbonic  acid  ;  but  as  yet  no  proof  of 
this  has  been  obtained.  Heiss  and  others  have  fed  animals  with  lactic 
acid  for  months  (three  hundred  and  eight  days,  for  example),  and  yet 
have  not  been  able  to  produce  osteomalacia.  It  seems  more  probable 
that  the  decalcification  is  due  to  the  action  of  carbonic  acid ;  it  is  pos- 
sible, and  the  hypersemia  of  the  medulla  favours  this  view,  that  in 
osteomalacia  we  have  to  deal  with  an  inflammatory  process  accom- 
panied by  an  increased  vascularity  and  an  abnormal  formation  of  car- 
bonic acid.  Examination  of  the  urine,  however,  does  not  always  show 
an  increased  excretion  of  earthy  phosphates,  a  thing  whieh  the  acid 
theory  would  lead  us  to  expect.  On  account  of  the  success  obtained 
in  the  treatment  of  the  disease  by  removal  of  the  ovaries,  Fehling- 
holds  the  opinion  that  it  is  caused  by  a  pathological  hyperactivity 
of  the  ovaries.  In  consequence  of  the  reflex  dilatation  of  the  vessels 
in  the  bone  there  is  a  passive  hypersemia,  and  later  an  absorption  of 
the  bone,  Petrone  calls  attention  to  the  increased  amount  of  nitric 
acid  contained  in  the  urine,  and  believes  that  osteomalacia  is  caused 
by  the  micro-organism  described  by  Schlossing  and  Miinz,  which  pro- 
duces nitric  acid.  In  one  case  of  non-puerperal  osteomalacia  observed 
by  Kobler,  with  pronounced  changes  in  almost  all  the  bones,  examina- 
tion of  the  ash  obtained  from  the  blood  revealed  a  considerable  increase 
of  sulphuric  acid  and  a  diminution  of  the  sodium  to  less  than  half  the 
normal  quantity.  The  rare  osteomalacia  of  men,  and  of  women  who 
are  not  pregnant  or  nursing,  depends,  according  to  Cohnheim,  in  the 
main  upon  disorders  of  digestion  or  of  assimilation,  combined  with 
a  lessened  absorption  of  lime. 

"We  have  practically  given  the  symptomatology  of  osteomalacia  in 
the  above  description.  The  disease  almost  always  begins,  as  we  have 
said,  during  pregnancy  or  during  the  puerperium,  with  severe  shooting 
pains  in  the  affected  bones.     Consequently  the  disease,  at  the  outset^ 


672  INJURIES  AND  SURGICAL  DISEASES  OF   BONE. 

is  often  confused  with  rheumatism,  until  the  changes  in  tlie  shape 
of  the  bones  enable  the  correct  diagnosis  to  be  made.  The  affection 
may  become  very  pronounced  during  a  single  pregnancy  or  a  single 
puerperium.  The  milder  cases  will  get  entirely  well ;  but  very  fre- 
quently the  disease  makes  pauses  in  its  progress,  and  then,  in  conjunc- 
tion with  another  pregnancy,  though  apparently  cured,  it  will  break 
out  again  with  fresh  intensity.  Recklinghausen  observed  osteomalacia 
in  young  subjects  in  combination  with  Basedow's  disease. 

The  prognosis  of  osteomalacia  is  very  unfavourable,  and  actual 
cures  are  exceedingly  rare.  ISTevertheless,  the  operative  removal  of 
the  ovaries  in  puerperal  osteomalacia,  recently  recommended  by  Feh- 
ling,  yields  surprisingly  good  results. 

The  treatment  of  osteomalacia  is  like  that  of  rickets  (see  pages  Q^)'^, 
669),  and  consists  primarily  in  the  administration  of  good  nutritious 
food,  also  cod-liver  oil,  iron,  lime,  quinine,  phosphorus,  and  arsenic. 
All  unfavourable  hygienic  conditions,  disturbances  of  nntrition,  and 
constitutional  anomalies  are,  as  far  as  possible,  to  be  done  away  with. 
If  the  woman  is  nursing  her  child,  she  must  be  forbidden  to  do  so,  and 
made  aware  of  the  danger  that  in  a  new  pregnancy  the  disease  may 
recur  with  increased  severity.  Great  interest  attaches  to  the  cures  of 
osteomalacia  recently  obtained  by  the  removal  of  the  ovaries.  The 
observation  has  been  made  that  after  removal  of  the  uterus  preg- 
nant women  suffering  from  osteomalacia  were  cured,  and  hence 
Fehling  recommended  simple  castration  for  the  same  purpose.  The 
success  of  this  procedure  is  so  marked  that  patients  •  with  a  very 
severe  form  of  the  disease  can  be  cured  and  allowed  to  attend  to  their 
employment  after  the  lapse  of  from  three  to  four  to  five  weeks. 
Petrone  believes  that  the  success  is  mainly  to  be  ascribed  to  the  narco- 
sis, and  not  to  the  operation,  as  he  has  cured  one  case  of  osteomalacia 
in  three  weeks  by  the  daily  administration  of  two  grammes  of  chloral 
hydrate,  the  nitric  acid  which  was  present  in  the  urine  disappearing  on 
the  fifth  day  of  the  treatment. 

The  castration  recommended  by  Fehling  for  osteomalacia,  with  or 
without  supravaginal  removal  of  the  uterus,  deserves  the  most  general 
consideration  because  of  the  success  which  has  already  been  obtained. 
Kummer  collected  in  1891  thirty-eight  successful  cases  of  double  cas- 
tration for  osteomalacia.  In  cases  of  pregnant  women  the  uterus  will 
usually  be  removed  as  well.  We  must  not  omit  to  state  that  in  rare 
instances  the  osteomalacia  of  women  also  gets  well  spontaneously. 

§  110.  Atrophy  and  Hypertrophy  of  Bone. — Atrophy  of  bone  is  due 
to  various  causes.  Every  absorption  of  fully  formed  bone  substance, 
which,  as  we  have  seen,  occurs  so  fi-equently  under  pathological  condi- 


110.] 


ATROPHY  AND  HYPERTROPHY  OF  BONE. 


673 


tions,  is  to  be  looked  upon  as  an  atrophy  of  bone.  The  absorption  of 
bone  substance  either  takes  place  on  the  external  surface  of  the  bone  or 
it  starts  in  the  medulla  and  advances  outward.  In  the  outer  (concen- 
tric) atrophy  the  bone  becomes  smaller  and  thinner,  while  in  the  case 
of  the  internal  (excentric)  atrophy  the  medullary  cavity  and  the  Haver- 
sian canals  grow  larger  and  the  bone  becomes  porous  (osteoporosis). 
Atrophy  of  bone  is  sometimes  congenital ; 
complete ''defects — e.  g.,  of  the  radius,  ulna, 
fibula,  or  tibia — occasionally  occur  and  cause 
corresponding  deformities  of  the  hand  and 
foot.  The  bone  in  question  has  in  all  proba- 
bility been  made  to  disappear  through  con- 
striction by  amniotic  threads,  folds,  or  strands. 
The  presence  of  cicatrices  and  the  combina- 
tion of  defects  in  the  bone,  with  intra-uterine 
amputations,  point  to  this  etiology. 

The  senile  atrophy  which  affects  the  bones 
of  the  skull  (the  cranial  vault,  the  inferior 
maxilla,  etc.)  and  of  the  extremities,  especially 
their  articular  ends,  is  a  special  form  of  bone 
atrophy.  The  senile  osteoporosis  of  the  neck 
of  the  femur  is  of  practical  importance,  as  the 
neck  gradually  becomes  depressed  and  may 
be  broken  by  a  very  slight  traumatism. 

A  common  cause  of  the  atrophy  of  a 
bone  is  disuse  of  the  latter  (atrophy  of  dis- 
use). We  have  said  that  this  follows  paral- 
yses, inflammations  of  joints,  temporary  im- 
mobilisation of  an  extremity  by  a  plaster-of- 
Paris  dressing,  etc.  The  disappearance  of 
the  acetabulum,  which  occurs  when  a  disloca- 
tion of  the  hip  is  not  reduced,  also  belongs  to 
the  atrophies  of  disuse.  This  form  of  atrophy 
may  take  place  in  certain  limited  portions  of 
a  bone,  as  in  the  callus  formed  after  a  frac- 
ture, those  portions  of   the  bone  substance 

gradually  disappearing  which  have  become  useless  for  the  function 
of  the  bone. 

Another  form  of  atrophy  of  bone  is  the  neuroparalytic  and  tropho- 
neurotic, which  occurs  in   conjunction   with  diseases  of  the  nervous 
system,  such  as  tabes,  or  as  a  result  of  changes  in  the  trophic  nerve 
fibres  or  afferent  nerves,   or  in  the  trophic  centres  in  the  anterior 
46 


Fig.  425. — Partial  (trophoneu- 
rotic ?)  atrophy  of  the  skele- 
ton (upper  part  of  the  body)  ; 
pelvis  and  lower  extremities 
are  well  -  developed  ;  thir- 
ty-five-year-okl  unmarried 
woman  (Mosengeil). 


674 


INJURIES  AND  SURGICAL  DISEASES  OF  BONE. 


Fig.  426. — Partial  giant  growth 
on  the  hand  (Curling  and 
BOhrn). 


bonis  of  grey  matter  in  the  spinal  cord  (Fig.  425).  Division  of  the 
sciatic  nerve  in  animals  has  been  found  to  cause  lengthening  and 
thickening  of  the  bone,  sometimes  with  an 
increase  in  weight  and  sometimes  a  diminu- 
tion in  weight  and  great  plial)ility  and  fragil- 
ity of  the  bone.  A  detailed  description  of 
the  trophoneurotic  diseases  of  the  bones  and 
joints  is  given  in  §  117. 

Local  arrest  of  longitudinal  growth  is 
caused  by  diseases  of  the  epiphyseal  cartilages, 
such  as  inflammation  or  suppuration,  or  it 
may  follow  their  ossification  at  too  early  a 
period  or  their  removal  in  too  extensive  a  re- 
section, etc.  Pressure,  inflammation,  and  the 
development  of  a  tumour  may  also  lead  to 
localised  atrophy,  to  wearing  away  of  bone, 
or  to  caries. 

Hypertrophy  of  Bone  is  either  limited  to  some  particular  portion  of 
a  bone,  as  in  the  formation  of  osteophytes,  or  it  affects  the  entire  bone, 
the  whole  yolume  of  the  latter  being  increased  or  only  its  length  or 

thickness.  The  hypertrophies  include  the 
hyperostoses  mentioned  on  a  previous 
page — i.  e.,  the  increase  in  volume  follow- 
ing periosteal  and  endosteal  formation  of 
bone,  and  the  osteosclerosis  or  thickening 
of  bone  tissue,  which  is  also  called  ebur- 
neatio  ossis. 

Leontiasis  Ossea. — Hypertrophy  of  the 
facial  and  cranial  bones  is  of  special  in- 
terest, the  so-called  leontiasis  ossea,  the 
etiology  of  which  is  very  obscure.     There 
is  probably  a  congenital  predisposition. 
The  affection  occurs  usually  in  young  in- 
dividuals of  both  sexes  who  are  otherwise 
healthy,  and  begins  as  a  painless,  increas- 
ing enlargement  of  the  malar  bone ;  the 
hypertrophy  then  gradually  attacks,  as  a 
rule,  almost  all  the  bones  of  the  face  and 
skull  symmetrically.     The  newly-formed 
bone,  which  is  at  first  spongy,  becomes  increasingly  harder.     There 
is  a  constant  increase  in  the  size  and  weight  of  the  bones.     The  sense 
of  smell  and  of  sight  are  lost,  and  after  a  number  of  years  (ten  to 


Fig.  427. — Giant  growth  of  the  upper 
extremity  and  the  right  side  of 
the  thorax  (Wagner). 


110.] 


ATROPHY  AXD  HYPERTROPHY  OF  BOXE. 


675 


thirty)  death  occurs,  sometimes  from  increasing  cerebral  compression. 
The  other  bones  remain  healthy.  ]^o  treatment  has  been  found  of  any 
avail. 

Helferich  and  others  have,  as  we  remarked  before,  increased  the 
development  of  bone  at  a  given  point  by  artificial  hypersemia,  pro- 
duced, for  example,  by  tying  off  the  extremity  with  an  elastic  tourni- 
quet drawn  moderately  tight  on  the  proximal  side  of  the  point  in  the 
bone  which  is  diseased.  This  procedure  is  worth  trying  in  the  case  of 
fractures  where  the  callus  formation  is  delayed 
and  insufficient,  and  in  pseudarthrosis,  and  also  to 
diminish  shortening,  etc.  (see  page  603). 

The  lengthening  which  bones  may  undergo  in 
conjunction  with  irritation  of  the  epiphyseal  car- 
tilages due  to  injuries  and  diseases  of  the  diaphysis 
or  neighbouring  joints  and  soft  parts,  is  also  a  mat- 
ter of  practical  importance.  As  Oilier  has  dem- 
onstrated experimental- 
ly, an  increase  in  the 
longitudinal  growth  of 
young  bones  is  very  eas- 
ily brought  about  by 
stimuli  of  various  kinds. 
This  explains  the  occur- 
rence of  the  increased 
longitudinal  growth 
which  takes  place  in 
conjunction  with  frac- 
tures, especially  those 
which  are  compound  and  heal  with  marked  inflammatory  reaction, 
or  which  follows  necrosis,  osteomyelitis,  large  ulcers  of  the  foot,  and 
diseases  of  joints.  Young  bones  which  have  been  dislocated  and  not 
replaced  take  on  increased  longitudinal  growth  if  they  are  freed  from 
the  pressure  of  the  superimposed  bone.  Thus,  for  example,  increased 
longitudinal  growth  of  the  radius  takes  place  after  dislocation  of 
its  head. 

Congenital  hypertrophy  of  bone  makes  its  appearance  in  the  form 
of  giant  growth  of  the  fingers  and  toes  (Fig.  426,  macrodactylia),  and 
also  as  giant  growth  of  an  entire  extremity  (Figs.  427,  428).  Accord- 
ing to  Wittelshofer's  statistics,  all  the  cases  of  true  giant  growth  hith- 
erto recorded  are  congenital  in  origin,  and  originate,  as  in  the  case  of 
the  very  considerable  monstrosity  illustrated  in  Figs.  427  and  428,  from 
an  abnormal  increase  of  growth  involving  all  the  tissues  of  one  part  of 


Fig.  428. — Giant  growth  of  the  lower  extremity  on  the  right 
side  and  the  upper  extremity  on  the  left  side. 


676  INJURIES  AND  SURGICAL  DISEASES  OP  BONE. 

the  body.  Giant  growth  is  possibly  a  congenital  trophoneurotic  dis- 
turbance. 

The  cases  of  acquired  hypertrophy  of  the  l)ones  and  soft  parts  (com- 
pensatory hypertrophy)  are,  of  course,  to  be  distinguished  from  this 
congenital  giant  growth.  P.  AVagner  has  recently  collected  several 
cases  of  congenital  and  acquired  giant  growth,  and  has  given  the  litera- 
ture on  this  subject  (Zeitschrift  fiir  Chir.,  Bd.  xxvi,  S.  210).  Bessel- 
Hagen  has  called  attention  to  the  various  anomalies  of  the  bones  and 
joints  which  occur  in  giant  growth. 

As  regards  the  treatment  of  partial  giant  growth,  elastic  bandaging, 
massage,  and  Weir  Mitchell's  cure  have  been  used  with  success  in  the 
milder  forms  of  the  affection.  In  severe  cases,  which  cause  much  trou- 
ble in  consequence  of  the  awkwardness  and  weight  of  the  affected 
extremity,  operative  measures  will  sometimes  be  necessary,  and  the 
enlarged  member  should  be  removed  (see  also  Treatment  of  Elephan- 
tiasis). 

Acromegaly,  a  disease  to  which  Marie,  in  1886,  first  directed  attention, 
must  be  carefully  distinguished  from  the  congenital  giant  growth.  In  acro- 
megaly, which  begins  about  the  tenth  to  the  twentieth  to  the  thii'tieth  year 
of  life,  and  lasts  ten  to  twenty  years  or  longer,  there  is  a  hypertrophy  of  all 
parts  of  the  body,  involving  both  the  bones  and  the  soft  i^arts,  especially  of 
the  head  and  extremities.  Multiple  exostoses  are  sometimes  found,  particu- 
larly on  the  long  bones  of  the  extremities.  In  some  cases  an  abnormal  in- 
crease in  height  takes  place  after  completion  of  the  normal  growth  of  the 
body.  The  hands  and  feet  have  the  appearance  of  paws.  In  the  head  the 
hypertrophy  affects  most  commonly  the  lower  jaw,  tongue,  under  lip,  and 
nose.  The  power  of  vision  may  be  completely  lost,  owing  to  the  pressure 
exerted  by  the  enlarged  sphenoid  bone  on  the  optic  nerve.  Hadden  and 
Ballame  state  that  the  disturbance  of  sight  is  caused  by  compression  of  the 
optic  chiasm  or  medullary  strias  of  the  optic  nerve  brought  about  by  the 
hypertrophy  of  the  pituitary  body.  The  vertebra?,  sternum,  and  ribs  are 
symmetrically  enlarged  ;  there  are  kyphotic  curvatures  of  the  spinal  column ; 
the  joints  are  deformed  ;  the  internal  organs,  brain,  muscles,  nerves,  etc., 
hypertrophy.  Atrophy  of  the  thyroid  gland  was  present  in  some  of  the 
cases,  and  in  place  of  hypertrophy  or  tumour  formation  of  the  pituitary  body 
there  was  degeneration  of  the  same.  In  consequence  of  thickening  of  the 
epiglottis,  the  laryngeal  cartilage,  and  the  vocal  cords,  respiration  may  be 
very  much  interfered  with,  so  that  death  may  take  place  suddenly  from  oede- 
ma of  the  glottis.  The  subjective  symptoms  presented  are  pains  in  the  head 
and  joints,  a  feeling  of  weakness,  and  para^sthesia.  A  steadily  increasing 
cachexia  finally  makes  its  appearance.  The  precise  cause  of  acromegaly  is 
still  obscure.  According  to  W.  A.  Freund,  the  affection  is  an  anomaly  of 
growth,  and  he  believes  that  its  immediate  cause  must  be  ascribed  to  an 
increased  flow  of  blood  to  the  dilated  vessels.  As  opposed  to  this  anomaly  of 
the  vessels  others  lay  stress  ujDon  the  neurotic  origin  of  the  disease — e.  g..  as 
the  result  of  central  or  peripheral  nervous  disturbances.     Inherited  predis- 


§  110.]  ATROPHY  AND  HYPERTROPHY  OF  BONE.  6YY 

position  to  the  disease  is  contested  by  Some  authorities  and  accepted  by- 
others.  It  probably  has  a  complex  etiology,  and  occurs  after  various  kind.s 
of  disorders.  Great  psychical  excitement  has  frequently  been  thought  to  be 
the  exciting  cause  of  the  afFection. 

Acromicria. — The  condition  the  reverse  of  acromegaly  is  called  acromicria 
(Stembo,  Reidel).  In  this  there  is  a  striking  atrophy,  especially  of  the  ter- 
minal portions  of  the  body  (head,  fingers,  toes),  together  with  a  process  of 
shrinkage,  which  attacks  different  organs  and  sometimes  the  entire  body. 
The  etiology  of  the  affection  is  very  obscure,  and  the  disease  must  be  care- 
fully differentiated  from  syringomyelia,  Morvan's  disease,  the  anaesthetic 
form  of  leprosy,  Raynaud's  disease,  and  from  analogous  syphilitic  or  dia- 
betic affections  of  the  fingers.  According  to  Stembo,  the  disease  begins  on 
the  fingers.  On  the  latter  there  is  often  a  development  of  blebs  or  iilcers, 
which  heal  slowly,  and  are  accompanied  by  intermittent  pain.  The  skin  on 
the  fingers  grows  more  and  more  thin,  cicatricial,  and  tense ;  all  the  nails 
perish,  the  fingers  become  shorter  and  less  movable,  and  the  entire  body 
grows  smaller,  from  atrophy  of  the  skin  and  the  soft  parts,  including  the 
tongue  and  oesophagus.  The  face  assumes  a  peculiar  stiff,  immovable,  and 
bird-like  expression.  There  are  no  disturbances  of  sensibility,  the  cutaneous 
reflexes  are  normal,  the  tendon  reflexes  diminished,  and  the  electrical  excita- 
bility of  the  muscles  and  nerves  is  slightly  increased. 

Daily  Variations  in  Height. — As  regards  the  well-known  fact  that  man 
becomes  shorter  in  the  course  of  the  day,  Merkel  has  made  some  accurate 
measurements  (mostly  upon  himself),  and  has  found  that  the  length  of  the 
body  in  the  morning  in  the  recumbent  position,  immediately  after  awak- 
ening, is  some  five  centimetres  more  than  in  the  evening  in  the  erect 
position.  The  loss  in  size  is  pai-tly  gradual  and  partly  sudden.  The  former 
is  due  to  the  gradually  increasing  compression  of  the  sole  of  the  foot  and  the 
intervertebral  fibro-cartilages ;  while  the  latter,  or  sudden  diminution  of 
stature  on  rising  from  the  horizontal  to  the  perpendicular  position,  is  brought 
about  by  compression  of  the  joints  of  the  lower  extremity,  a  shortening  of 
eight  millimetres  taking  place  in  the  region  of  the  ankle  joint,  of  two  to 
three  millimetres  at  the  knee,  and  of  one  centimetre  at  the  hip.  This  lessen- 
ing of  the  length  of  the  lower  extremities  is  mainly  caused  by  compression 
of  the  elastic  articular  cartilages  and  by  the  sinking  of  the  caput  femoris 
into  the  cavity  of  the  acetabulum,  which  occurs  upon  standing  in  the  erect 
position. 

Lymphadenia  Ossium  (Nothnagel).— A  peculiar  kind  of  pernicious  bone 
disease,  which  has  been  described  by  Nothnagel,  requires  mention  at  this 
point.  It  was  observed  in  a  man  twenty-four  years  of  age,  and  terminated 
fatally  in  a  year  and  a  half,  the  patient  having  been  afflicted  with  severe 
pains,  thickening  of  the  bones,  and  steadily  increasing  cachexia.  The 
autopsy  revealed  a  very  extensive  development  of  a  lymphadenoid  tissue, 
with  a  great  number  of  Charcot-Neumanu  crystals  in  the  bones,  and  at  the 
same  time  a  periosteal  and  medullary  new  formation  of  bone.  The  medulla 
had  almost  completely  disappeared.  Nearly  all  the  bones  were  diseased, 
the  phalanges  of  the  hands  and  feet  and  the  bones  of  the  face  alone  remain- 
ing unaffected.  The  lymph  glands  and  the  spleen  were  enlarged,  probably  to 
compensate  for  the  lack  of  medullary  tissue,  with  its  power  of  making  blood. 


678 


INJURIES  AXD   SURGICAL   DISEASES  OF  BOXE. 


§  111.  The  Tumours  of  Bone. — The  tumours  peculiar  to  bone  (os- 
teoma, exostosis,  osteosarcoma,  enchondroma,  soft-bone  tumours,  cyst, 
etc.)  will  be  described  in  §§  125-130,  where  we  shall  take  up  the  sub- 
ject of  tumours  in  general.  At  present  we  shall  only  briefly  discuss 
the  parasitic  tumours  of  bone. 

Of  animal  parasites  there  occur  in  bone  the  echinococcus  and  the 
Cysticercus  cellulosfp,  the  latter  being  very  rarely  met  with.  Volk- 
niann  mentions  one  case  of  Froriep's,  in  which  this  parasite  was  found 
in  the  first  phalanx  of  tlie  middle  finger,  the  symptoms  being  those  of 
a  suppurative  periostitis. 

Of  echinococcus  of  bone  there  are  fifty  known  cases. 

Echinococcus  of  Bone.— The  taenia  echinococcus, 
as  is  Avell  known,  is  a  four-jointed  parasite  about 
four  millimetres  long,  which  lives  in  the  intesti- 
nal canal  of  the  dog ;  and  only  the  cysticercus  of 
this  taenia,  after  the  introduction  of  the  ta?nia  eggs 
into  the  intestinal  canal,  occurs  in  man.  In  what- 
ever organs  the  embryo  lodges,  the  liver  being  the 
one  most  commonly  aflfected,  characteristic  cystic 
tumours  develop.  The  cyst  is  made  up  of  a  lamel- 
lar, very  elastic  cuticular  layer  (ectocyst),  on  the 
inner  surface  of  which  is  a  granular  parenchyma- 
tous layer.  From  this  inner  layer  the  so-called 
brood-capsules  develop,  and  upon  these  are  formed 
the  scolices  in  great  numbers.  The  echinococcus 
cyst  either  remains  single — unilocular — or  it  goes 
on  to  form  daughter  cysts  by  exogenous  and  endog- 
enous proliferation.  The  size  of  the  cysts,  espe- 
cially in  the  liver,  is  often  very  considerable.  The 
echinococcus  multilocularis  is  another  form  of  the 
echinococcus,  which  forms  in  the  liver  only  small 
cysts  in  great  numbers,  varying  from  the  size  of  a 
millet  grain  to  that  of  a  pea,  which  are  surrounded 
by  a  thick,  tough,  diffuse  ma.ss  of  connective  tissue. 
The  echinococcus  cysts  excite  a  local  inflamma- 
tion which  leads  to  the  formation  of  a  connective- 
tissue  capsule.  The  cysts,  after  attaining  the  size  of 
a  walnut  or  apple,  often  die,  and  their  fluid  contents 
become  absorbed,  a  cheesy,  fatty  detritus  or  calcifi- 
cation being  then  found  inside  the  shrunken  sac. 
In  other  instances  the  cysts  grow  so  large  as  to 
become  dangerous,  and  by  penetrating  or  bursting  into  some  cavity  of  the 
body  give  rise  to  severe  inflammations.  For  a  more  detailed  description  of 
echinococcus,  see  Vol.  III.  §  161. 

The  echinococcus  develops  in  bone,  especially  in  the  medulla  (Fig. 
429),  and  occasionally  forms  at  some  point  where  the  bone  has  been  sub- 


FiG.  42S. — Echinococcus  of 
the  femur  and  tibia  of  a 
fifty-two-year-old  wom- 
an :  a,  large  echinococcus 
evst.  Amputatio  femoris 
(Hahn). 


111.] 


THE  TUMOURS  OF  BOXE. 


6Y9 


VvkA\ 


Fig.  430. — Echinococeus  of  the  pelvic  bones  on  the 
right  side,  with  well-marked  absorption  of  the 
bones  of  the  pelvis  and  head  of  the  femm-  in  a 
twenty-five-year-old  peasant  woman  ( Viertel). 


jected  to  a  traumatism.  The  echinococeus  cysts  of  bone  are  of  slow, 
indolent  growth,  and  after  the  lapse  of  years  sometimes  gives  rise  to 
painful  tumours,  which  at  the  outset  present  the  appearance  of  a  cen- 
tral bone  tumour 
and  subsequently 
of  a  bone  cyst. 
The  affection  oc- 
casionally remains 
latent  for  several 
years.  Echinococ- 
eus cysts  usually 
vary  in  size  f]*om 
that  of  the  head  of 
a  pin  to  that  of  a 
pea,  or  they  form 
large  cysts  (Fig. 
429,  a)  which  commonly  break  through  the  cortex  after  they  have 
existed  a  long  time,  and  invade  the  surrounding  soft  parts,  muscles, 
vessels,  and  nerves,  or  neighbouring  joint  (see  page  680).  As  Bergmann 
has  remarked,  there  is  sometimes  a  formation  of  abscesses  in  the  tissues 
around  the  bone,  which  after  being  incised  show  no  tendency  to  heal, 
and  may  lead  one  to  suppose  that  there  is  a  necrosis  present.  The 
pus  at  times  is  remarkably  rich  in  cholesterin  crystals,  a  fact  which  is 
of  importance  for  the  diagnosis.  The  destruction  of  bone  is  not  infre- 
quently very  considerable  (Fig.  430).  The  periosteum  and  medulla 
are  usually  passive,  and  hence  the  process  does  not  ordinarily  result  in 
regenerative  growth  of  the  bone  from  the  periosteum  or  medulla.  It 
is  worth  noting  that,  as  Gangolphe  says,  the  multilocular  form  of 
echinococeus  of  bone  is  by  far  the  most  common  ;  it  was  found  thirty- 
two  times  in  thirty-seven  cases,  and  only  in  five  instances  was  encysted 
echinococeus  present  (which  is  much  the  more  common  form  in  the 
soft  parts,  especially  in  the  liver).  Of  fifty-two  cases,  twenty-six  were 
of  the  hollow  bones  (eleven  humerus,  eight  tibia,  six  femur,  one  pha- 
lanx) and  eighteen  of  the  flat  bones  (eleven  pelvis,  four  each  involving 
the  skull,  scapula,  and  sternum,  and  the  ribs  once). 

The  diagnosis  can  only  be  made  with  certainty  when  the  soft,  fluctuat- 
ing tumours  have  broken  througli  the  bone,  or  when  a  portion  of  their  con- 
tents can  be  withdrawn  by  an  exploratory  puncture.  In  the  case  of  the  long 
hollow  bones  the  nature  of  the  disease  is  occasionally  revealed  by  the  occur- 
rence of  a  spontaneous  fracture. 

The  prognosis  is  governed  by  the  location  of  the  disease,  echinococeus 
of  the  bones  of  the  skull  and  of  the  vertebrae  and  pelvis  being  the  most 
-unfavourable,  while   the   echinococeus  of  the  extremities  is  less  so.     Gan- 


6S0  INJURIES  AND  SURGICAL  DISEASES  OF  BONE, 

golphe  states  that  out  of  seven  cases  of  echinococcus  of  the  vertebrae,  six 
died  of  sepsis  after  the  operation,  while  of  nineteen  patients  with  echino- 
coccus of  the  extremities  only  four  died. 

The  treatment  consists  in  as  complete  a  removal  as  possible  of  the 
cyst  as  well  as  of  the  diseased  bone,  or,  when  this  cannot  be  done,  in 
incision,  with  destruction  of  the  membrane  by  means  of  the  sharp 
spoon,  Paquelin  thermo-cauterj,  etc.  In  the  case  of  the  extremities, 
amputatio7i  or  disarticulation  will  often  be  necessary.  Of  the  thirty- 
six  cases  of  echinococcus  of  bone  collected  by  Reszey  and  Hahn, 
twenty  were  operated  upon,  and  of  these  fourteen  were  cured  (two 
by  incision,  twelve  by  amputation).  At  all  events  the  treatment  should 
be  as  enei'getic  as  possible  so  as  to  prevent  recurrences. 

Echinococcus  in  Joints. — Occasionally,  as  we  have  remarked  before, 
an  echinococcus  of  bone  breaks  through  into  the  neighbouring  joint 
(Fischer  found  ten  such  cases  in  literature) ;  but  it  is  extremely  rare 
for  the  parasite  to  lodge  primarily  in  the  joints.  Of  the  above-men- 
tioned ten  cases,  eight  affected  the  hip  joint,  one  the  knee,  and  one  an 
interphalangeal  joint.  Of  echinococcus  cysts  of  the  pelvic  bones  with 
perforation  into  the  hip  joint,  only  one  case  has  been  cured  by  opera- 
tion (Bardeleben).  The  treatment  of  this  affection  of  the  joints  de- 
mands very  energetic  procedures  (resection,  or  even  amputation). 


CHAPTER  lY. 

LNJUKIES    AND    DISEASES    OF   JOINTS. 

Review  of  the  anatomy  of  joints. — The  acute  inflammations  of  joints  :  Acute  serous, 
sero-fibrinous,  and  suppurative  synovitis. — Acute  polyarticular  rheumatism.^ — The 
secondary  inflammations  of  joints  occurring  in  the  course  of  acute  infectious 
diseases  (metastatic  inflammations  of  joints). — Gonorrhoeal  arthritis. — The  acute 
arthrites  occurring  in  the  course  of  syphilis. — Arthritis  urica  (gout). — Gout  from 
lead  poisoning. — Treatment  of  acute  inflammations  of  joints. — The  chronic  inflam- 
mations of  joints:  Chronic  hydarthros. — Chronic  articular  rheumatism. — Chronic 
suppuration  of  joints. — Fungous  (tubercular)  arthritis,  joint  caries. — Syphilitic 
arthritis. — Arthritis  deformans. — Diseases  of  joints  in  bleeders  (hjemophilia). — 
Joint  bodies. — Articular  neuralgias,  articular  neuroses  (hysterical  joint  affections). 
— Neuropathic  inflammations  of  bones  and  joints. — Anchyloses. — Deformities  of 
joints  (contractures). — Echinococcus  of  the  joints  (see  page  680). — The  injuries  of 
joints :  Subcutaneous  injuries  (contusions,  sprains). — Dislocations  (luxations)  of 
joints. — Wounds  of  joints. — Appendix  :  Gunshot  wounds. — Remarks  upon  military 
surgery. 

§  112.  Review  of  the  Anatomy  of  the  Joints.— It  is  well  known  that 
the  cavities  of  the  joints  of  the  cartilaginous  skeleton  of  the  fcetiis  are 
made  by  dehiscence,  or  softening  and  liquefaction  of  the  formative 
tissue  remaining  between  the  cartilaginous  layers.  They  develop  later 
than  the  ligaments  of  the  capsule,  which,  as  processes  of  the  perichon- 
drium, stretch  across  the  space  lying  between  the  ends  of  the  cartilages. 
The  articulations  between  the  bones  are  commonly  divided  into  two 
classes  :  the  synarthroses  and  the  diarthroses.  The  synarthroses  are 
characterised  by  having  a  cartilaginous  or  fibrous  layer  interposed  be- 
tween the  bone  surfaces,  which  is  connected  to  the  periosteum,  the 
latter  extending  from  one  bone  to  the  other.  In  the  diarthroses  the 
continuity  is  completely  interrupted,  and  they  are  provided  with  a 
loose  capsule,  which  is  generally  strengthened  by  accessory  ligaments. 
The  inner  surface  of  the  capsule  of  a  joint,  or  the  so-called  synovial 
membrane,  is  covered  usually  by  a  single  layer  of  endothelium,  which, 
as  my  investigations  show,  very  often  extends  over  the  synovial  fringes 
and  interarticular  ligaments  as  far  as  they  lie  free  in  tlie  cavity  of  the 
joint,  but  under  normal  conditions  does  not,  as  a  rule,  cover  the  point 

681 


682 


INJURIES  AXD   DISEASES   OF   JOINTS. 


of  origin  of  tlie  synovial  membrane  at  the  articular  cartilage.  In  the 
foetns  the  cartilage  is  ordinarily  partially  covered  by  endothelium,  and 
after  birth,  if  a  joint  remains  quiet  for  any  length  of  time,  the  endo- 
thelium will  grow  over  por- 
_  tious  of  the  articular  cartilages 
W%  and  other  parts  of  the  joint 
.t'  which  present  free  surfaces. 
.;  As  an  individual  increases  in 
age  the  endothelium  of  the 
synovial  membrane  l)ecomes 
moditied  at  the  places  of  great- 
est friction,  and  it  is  often 
completely  absent  here  (Ha- 
gen  -  Torn,  Braun).  On  the 
iuner  surface  of  the  synovial 
membrane  there  are  found 
thread  -  like  outgrowths,  the 
synovial  villi  (Figs.  431,  432), 
which  can  be  seen  especially 
well  as  floating  structui"es  when 
a  joint  like  the  knee  is  opened  under  water.  Some  of  the  villi  con- 
tain vessels  (Fig.  432),  others  do  not ;  and  some  of  them  are  single 
filaments,  while  others  are  branched  and  are  provided  with  daughter 


Fig.  431. — Synovial  villi  (knee-joint).     Glycerin- 
osmic  acid,     x  30. 


Fig.  432. — Vascular  synovial  villi.     Five  per  cent,  bichromate  of  potassium.     Knee-joint  of 

man.      x  30. 


§  112-] 


REVIEW  OF   THE   AXATOMY  OF   THE  JOIXTS. 


683 


villi.     According  to  the  nature  of  the  tissue,  cartilage  villi,  fibrous 
villi,  fat  villi,  and  mucous  villi  can  be  distins^uislied,  while  between 


Fig  433  — Lymphatics  of  the  synovial  membiane  (knee  joint  of  an  o\)      x  20 


wnrww 


these  individual  kinds  there  are  numerous  transition  forms.     Cartilage 
cells  are  very  often  found  in  the  fibrous  villi. 

The  joint  capsules  are,  as  Fig.  433  shows, 
very  richly  suppKed  with  lymph  vessels — a 
matter  of  great  practical  importance.  It  is  sup- 
posed that  there  are  open  communications — 
stomata,  as  they  are  called — l)etween  the  lymph 
channels  and  the  joint  cavity  on  the  inner  sur- 
face of  the  articular  capsule,  as  there  are  in 
other  serous  membranes  ;  but  as  yet  I  believe 
no  one  has  been  able  to  demonstrate  them. 

The  hyaline  cartilage  is  only  apparently 
homogeneous.  As  I  was  the  first  to  show 
(Archiv  fiir  Anat.  und  Phys.,  1877),  it  can  be 
demonstrated  by  means  of  trypsin,  or  the  pro- 
longed action  of  permanganate  of  potassium, 
that  hyaline  cartilage  is  really  made  up  of  fibres 
which  are  bound  together  by  a  cement  sub- 
stance. The  latter  is  dissolved  by  the  above- 
mentioned  materials,  especially  by  the  action  of  trypsin  at  a  tempera- 
ture of  38°  to  40°  C.  (101.4°  to  104°  F.)  in  the  incubating  oven,  and 


Fig.  434.— Hyalihc    :a:  :::.. 
treated   in    an  inouoator 
•with  trypsin.     Network 
arrangement  of  the  fibres. 
X  150. 


684 


INJURIES  AND  DISEASES  OF  JOINTS. 


the  fibres  are  then  made  evident  (Figs.  434,  435,  436).  They  may  have 
a  lamellar  arraugeuieiit,  as  iu  Fig.  435,  or  form  a  network,  a  reticulated 
structure  (Figs.  434,  436).  Through  our  knowledge  that  even  hyaline 
cartilage  is  constructed  of  fibres,  we  can  more  readily  understand  the 
various  changes  which  occur,  for 
example,  in  the  calcification  of  the 
callus  or  in  the  repair  of  wounds 


'|x  .  . 


^^3;*iEr- 


Fig.  435. — H}"aline  cartilage  treatei I  in  an  incu- 
bator with  trypsin.  Arrangement  of  the 
fibres  in  the  tbrm  of  lanielhis.     x  240. 


Fig.  4;:'.t;. —  liyalmc  cartilage  treatdl  m  a  hatch- 
ing oven  with  trypsin.  Network  arrange- 
ment of  the  fibres,     x  240. 


of  cartilage,  also  the  fibrillation  of  hyaline  cartilage  which  takes  place 
in  chronic  joint  disease,  etc.  We  have  Budge  to  thank  for  his  beau- 
tiful investigations  upon  the  circulatory  channels  in  cartilage. 

The  views  of  authorities  vary  as  to  the  origin  of  the  synovia,  but 
my  own  investigations  have  led  me  to  believe  that  it  is  mamly  formed 
by  the  mucous  and  fat  villi,  partly  by  secretion  and  partly  by  a  break- 
ing up  of  their  cellular  elements.  However,  this  is  not  the  place  to 
discuss  any  more  fully  the  anatomy  and  physiology  of  joints,  and  I 
must  refer  the  reader  to  the  text-books  on  these  subjects  ;  but  I  have 
thought  it  wise  to  briefly  touch  upon  some  of  the  questions  which  are 
particularly  important  as  regards  the  subject  of  diseases  of  joints.  The 
mucous  bursse  are  described  in  §  99. 

§  113.  The  Acute  Inflammations  of  Joints. — We  distinguish,  accord- 
ing to  the  nature  of  the  exudate  in  the  acute  inflammations  of  joints, 
two  main  varieties:  the  serous  and  the  suppurative. 

1.  The  acute  serous  synovitis  is  usually  characterised  by  the  pres- 
ence of  a  cloudy,  serous  liquid  containing  a  greater  or  less  number  of 
fine  flakes  of  fibrin.  If  there  is  a  considerable  quantity  of  the  latter 
present  the  synovitis  is  also  called  sero-fibrinous.  The  other  patho- 
logical changes  which  occur  in  a  serous  synovitis  consist  in  a  varying 
amount  of  hypersemia  and  swelling,  and  upon  microscopical  examina- 
tion there  are  usually  found  here  and  there  small  collections  of  leuco- 
cytes or  extravasations  of  blood. 


§  113.]  THE   ACUTE   INFLAMMATIONS   OF  JOINTS.  685 

The  clinical  course  of  a  serous  synovitis  is  briefly  as  follows :  If 
we  suppose,  for  example,  that  the  knee  joint  is  the  one  affected,  it  is 
usually  swollen  and  feels  hot,  is  tender  to  the  touch,  and  on  palpation 
fluctuation  is  plainly  made  out,  and  the  patella  is  lifted  from  its  normal 
position — it  "  floats."  Active  and  passive  movements  of  the  joint  are 
possible,  but  cause  pain.  There  is  either  no  fever  at  all  or  only  a  very 
slight  amount  of  it.  The  further  course  of  the  disease  is  in  the  main 
dependent  upon  the  cause,  but  it  is  ordinarily  favourable,  and  if  proper 
treatment  is  adopted  recovery  will  very  speedily  ensue.  Occasionally 
an  acute  serous  synovitis  will  change  into  the  suppurative  form  or  into 
a  chronic  hydarthros.  ISTot  infrequently  after  recovery  from  the  acute 
hydarthros  there  is  a  pronounced  tendency  to  relapses.  Garre  found  as 
the  cause  of  one  case  of  recurrent  synovitis  of  the  ankle  joint  an 
encapsulated  osteomyelitic  focus  in  the  internal  malleolus.  After  this 
had  been  chiseled  open  and  treated  the  synovitis  did  not  recur.  The 
pus  in  the  osteomyelitic  focus  contained  virulent  staphylococci. 

2.  Acute  suppurative  synomtis  and  arthritis  is  characterised  ana- 
tomically by  the  formation  of  a  purulent  or  fibrino-purulent  exuda- 
tion. It  either  follows  a  serous  or  sero-fibrinous  inflammation  or  begins 
as  such.  In  addition  to  the  pure  or  flocculent  pus  which  is  found  in 
the  joint,  there  is  also  usually  present  a  marked  swelling  and  hyperae- 
mia  of  the  synovial  membrane  and  ligaments  upon  which  a  fibrino- 
purulent  material  is  deposited,  sometimes  containing  foci  of  pus. 
Furthermore,  the  articular  cartilages  become  dull  in  appearance,  and 
there  is  an  even  extension  of  the  synovial  membrane  over  their  edges 
in  the  form  of  vascular,  newly  developed,  delicate  connective  tissue. 
The  milder  grades  of  suppurative  arthritis,  without  deep  destruction 
of  the  synovial  membrane,  we  shall  designate  as  catarrhal  suppuration 
of  a  joint.  In  the  cases  of  longer  duration,  or  in  the  more  severe  forms 
of  suppuration,  all  portions  of  the  joint  are  attacked  by  the  suppuration, 
the  cartilage  undergoes  fibrillation  and  here  and  there  becomes  necrotic. 
The  suppuration  may  extend  to  the  bones  and  the  medulla,  and,  after 
breaking  through  the  capsule  of  the  joint,  give  rise  to  periarticular 
abscesses,  etc.  In  the  worst  forms  of  acute  suppurative  arthritis  putre- 
factive changes  take  place,  sometimes  accompanied  by  a  marked  evo- 
lution of  gas.  Suppurative  infiammation  of  a  joint  may  terminate  in  a 
restitutio  ad  integrum^  in  recovery  with  partial  or  total  stiffness  of 
the  joint  (anchylosis),  or  in  death. 

The  clinical  course  of  an  acute  suppurative  inflammation  of  a  joint 
like  the  knee  is  characterised  by  severe  pain,  by  high  fever,  which 
often  begins  suddenly  with  a  chill,  by  great  swelling,  and  by  pro- 
nounced disturbance  of  function.     The  knee  is  usually  slightly  flexed. 


686  INJURIES  AND  DISEASES  OP  JOINTS. 

and  the  least  attempt  at  passive  motion  causes  the  most  intense  pain. 
The  skin  generally  feels  very  hot,  and  is  reddened.  At  the  outset  fluc- 
tuation is  ordinarily  not  present,  but  becomes  capable  of  detection  as 
the  amount  of  pus  increases.  A  characteristic  feature  of  suppuration 
of  a  joint  is  the  oedematous  swelling  of  the  parts  surrounding  it  or  of 
the  entire  extremity.  The  subsequent  course  of  the  disease  depends 
upon  the  nature  of  the  infection,  and  especially  upon  whether  the  sup- 
purative arthritis  receives  early  antiseptic  treatment.  If  the  joint  is 
opened  and  drained  antiseptically  at  an  early  stage,  recovery  with  a 
movable  joint  may  still  be  obtained ;  and  even  in  neglected  cases  a 
restitutio  ad  integrum  is  possible  with  the  help  of  antiseptics.  In 
other  instances  the  acute  suppuration  becomes  chronic.  Yery  often 
recovery  takes  place  with  more  or  less  stiffness,  or  with  partial  or 
complete  obliteration  of  the  joint.  When  the  joint  is  obliterated  the 
granulation  tissue  which  is  present  changes  into  cicatricial  tissue — i.  e., 
a  cicatricial  connective-tissue  anchylosis  develops,  though  sometimes 
the  stiffness  is  due  to  bony  union  of  the  articular  ends  of  the  bones 
(bony  anchylosis ;  see  §  118,  Anchylosis).  The  worst  cases  terminate 
in  death  from  pysemia  or  septicaemia,  the  latter  coming  on  with  great 
rapidity  in  the  case  of  putrefaction  of  a  joint,  unless  operative  measures 
are  very  speedily  and  energetically  adopted. 

Suppuration  of  joints  in  ai'thropathies  is  described  in  §  117,  and 
the  spontaneous  dislocations  which  occur  in  acute  inflammations  of 
joints  in  §  122  (Luxations). 

The  contractures  which  take  place  in  the  course  of  acute  joint  dis- 
eases are  mainly  reflex  in  their  nature  (see  pages  569  and  575). 

The  Primary  Acute  Suppurative  Synovitis  of  Small  Children.— Krause 

has  recently  described  a  primary  acute  suppvirative  synovitis  of  small  chil- 
dren on  the  basis  of  observations  made  in  Yolkmann's  clinic.  The  afPection 
occurs  not  infrequently  in  the  form  of  catarrhal  suppurative  arthritis  in 
children  from  one  to  four  years  of  age,  is  always  monarticular,  and  attacks 
most  commonly  the  shoulder,  ankle,  elbow,  and  hip  joints.  The  course  is 
very  acute,  and  is  accompanied  by  the  symptoms  of  a  phlegmon ;  but  after 
freely  opening  the  joint  recovery  usually  takes  place  rapidly  without  dis- 
turbance of  function.  Satisfactory  results  are  often  obtained  even  in  the 
cases  where  the  pus  has  spontaneously  ruptured  externall3^  and  in  neglected 
cases.  Not  infrequently  spontaneous  luxations  occur.  Krause  found  the 
Streptococcus  pyogenes  in  the  pus.  Sometimes  suppurative  inflamma- 
tions of  joints  are  observed  during  early  childhood  in  conjunction  with 
injuries  or  the  acute  exanthemata  ;  they  are  generally  caused  by  the  Staph- 
ylococcus pyogenes  aureus  or  albus,  and  have  a  i^ronounced  pytemic 
character. 

Croupous  Synovitis. — Many  authorities,  including  Bonnet,  have  recog- 
nised, in  addition  to  the  serous  and  suppurative  synovitis,  a  crouj)ous  syn- 


§113.]  THE  ACUTE  INFLAMMATIONS   OF  JOINTS.  68T 

ovitis  which  is  analogous  to  the  croupous  inflammation  of  mucous  mem- 
branes. In  the  croupous  synovitis  there  are  found  in  the  cavity  of  the  joint 
large  amounts  of  coagulated  fibrin  ;  the  aifected  joints  are  very  painful,  but 
only  slightly  swollen,  and  fluctuation  is  absent.  The  course  of  this  more  or 
less  dry  arthritis  is  unfavourable,  inasmuch  as  the  joint  becomes  obliterated 
in  the  majority  of  instances,  and  firm  anchylosis  results.  As  a  matter  of 
fact,  there  are  infiammations  of  joints  which  run  a  very  dry  course ;  but 
it  seems  to  me  questionable  whether  in  these  cases  there  is  really  a  croupous 
inflammation  of  the  joint. 

Etiology  of  Acute  Inflammations  of  Joints. — The  causes  of  acute  pri- 
mary iniiammations  of  joints  are  in  the  main  traumatic,  and  are  chiefly 
to  be  ascribed  to  infection  of  some  injury  by  micro-organisms.  Every 
suppurative  arthritis  is  due  to  the  presence  of  bacteria.  In  the  case 
of  a  serous  synovitis,  however,  taking  cold  cannot  be  left  out  of 
account  as  a  primary  or  exciting  cause.  Primary  acute  inflammations 
of  joints  very  often  originate  secondarily — i.  e.,  they  are  either  the 
result  of  disease  of  the  adjoining  tissues,  such  as  the  medulla,  perios- 
teum, etc.,  or  they  are  the  local  expression  of  a  general  systemic  infec- 
tion— in  other  words,  they  are  metastatic  inflammations  which  gener- 
ally develop  simultaneously  in  several  joints.  In  the  latter  category 
belong,  for  example,  the  inflammations  of  joints  occurring  in  the  course 
of  pyaemia,  typhoid  fever,  the  acute  exanthemata,  and  of  pneumonia  in 
consequence  of  infection  by  Frankel's  pneumococcus,  also  polyarticular 
rheumatism,  arthritis  urica  (gout),  gonorrhoeal  rheumatism,  the  inflam- 
mations of  joints  arising  in  the  course  of  syphilis,  chronic  lead  poison- 
ing, etc.  We  must  refer  the  reader  to  the  text-books  on  internal  medi- 
cine for  the  description  of  acute  polyarticular  rheumatism.  It  will 
suffice  to  say  here  that  the  entire  course  of  this  disease  suggests  an  in- 
fection by  micro-organisms  with  localisation  in  the  joints  and  other 
serous  cavities  (the  endocardium,  for  example).  The  inflammation  of 
the  joints  is  generally  serous,  but  it  may  occasionally  be  suppurative  in 
its  nature.  The  Diplococcus  jpneumonicE  of  Frankel  and  Weichselbaum 
has  been  found  in  the  pus  in  acute  articular  rheumatism.  At  all 
events,  there  are  many  different  kinds  of  micro-organisms  concerned  in 
the  so-called  acute  polyarticular  rheumatism.  The  acute  rheumatism 
that  occurs  during  pregnancy  very  frequently  runs  a  severe  and  pro- 
tracted course,  usually  lasting  much  longer  than  the  pregnancy,  and 
terminating  in  anchylosis,  particularly  of  the  knee  and  wrist  (ISToorden). 

The  Secondary  Inflammations  of  Joints  which  Occur  in  the  Course  of 
Acute  Infectious  Diseases  (Pyaemia,  Acute  Exanthemata,  etc.). — The  in- 
flammations of  joints  which  occur  in  the  course  of  acute  infectious  dis- 
eases (pyaemia,  erysipelas,  puerperal  fever,  measles,  scarlet  fever,  small- 
pox, typhoid  fever,  diphtheria,  pneumonia,  mumps,  glanders,  dysentery, 


^38  INJURIES  AND  DISEASES  OF  JOINTS. 

etc.)  ai-e  mostly  of  the  suppurative  variety,  and  the  bacterial  forms 
which  are  characteristic  of  the  primary  disease  are  usually  found  in  the 
exudate  contained  in  the  joint.  In  the  case  of  pneumonia  the  suppu- 
rative arthritis  following  infection,  by  Friinkers  pneumococcus  may 
develop  before  or  after  the  pneumonia  itself.  The  pysemic  inflamma- 
tions of  joints  run  the  course  of  an  acute  suppurative  catarrh  or  of  an 
acute  pyaemic  gangrenous  arthritis,  and  the  disease  is  almost  always 
multiple.  If  the  patient  recovers  from  the  pyaemia  the  inflammation 
<jf  the  joints  will  ordinarily  subside  with  great  rapidity,  and  not  infre- 
quently the  joints  will  regain  perfect  motion  where  one  would  expect 
stiffness.     Other  cases  run  a  very  chronic  course,  like  cold  abscesses. 

The  inflammations  of  joints  which  occur  in  the  course  of  the  acute 
exanthemata  (scarlet  fever,  measles,  small-pox,  typhoid  fever,  di])hthe- 
ria,  dysentery,  etc.)  present  the  picture  either  of  acute  polyarticular 
rheumatism  or  of  suppurative  pysemic  arthritis.  During  convales- 
cence from  the  acute  infectious  diseases,  however,  we  meet  with  pro- 
nounced, serous,  monarticular  exudations  into  the  joints  which  only 
cause  a  slight  amount  of  pain ;  this  is  particularly  apt  to  happen  in 
tvphoid  fever.  O.  AVitzel  has  recently  called  attention  to  the  frequent 
occurrence  of  inflammations  of  bones  and  joints  during  acute  infectious 
diseases.* 

Suppuration  in  Neuropathic  Bone  and  Joint  Disease. — Suppuration  in 
neuropathic  bone  and  joint  disease  is  discussed  in  §  117.  The  analgesia 
which  is  the  result  of  disease  of  the  spinal  cord  (tabes,  syringomyeliii, 
etc.)  and  peripheral  nerves  is  an  important  etiological  factor  in  the 
production  of  this  kind  of  suppurative  arthritis,  for  the  reason  that  tiie 
patients,  in  consequence  of  the  absence  of  their  sense  of  pain,  neglect 
injuries  which  they  receive,  and  this  allows  suppurative  infection  to 
take  place. 

Gonorrhceal  Arthritis. — Gonorrhoeal  inflammations  of  joints  occur 
most  commonly  during  the  first  month  of  the  gonorrhoea.  Nolan  found 
that  gonorrhceal  arthritis  developed  sixty-four  times  in  the  first  month, 
eleven  times  in  the  second  month,  and  twelve  times  later  on — in  some 
cases  even  years  afterward  (Bennecke).  Generally  speaking,  the  joints 
become  the  seat  of  metastatic  infiammation  only  when  the  gonorrhoea 
has  involved  the  deeper  portions  of  the  urethra,  thus  allowing  the  mi- 
cro-organisms to  get  into  the  circulation  more  easily.  Aman  has  found 
gonococci  in  the  blood.  The  tendons  and  tendon  sheaths,  bursae,  nerves, 
eye,  endocardium,  and  pericardium  are  also  sometimes  attacked  by 
metastatic  inflammation  in  gonorrhoea.  Gonorrhceal  inflammations  of 
joints  are  only  rarely  caused  by  the  gonococcus ;  in  the  majority  of 
*  Bonn,  Max  Cohen  &  Son,  1890,  p.  146. 


§  113.] 


THE  ACUTE  INFLAMMATIONS  OF  JOINTS. 


689 


cases  staphylococci,  streptococci,  pnenmococci,  etc.,  have  been  found. 
The  pus  cocci  occur  in  the  exudate  either  alone  or  with  gonococci. 
Generally  speaking,  it  is  not  often  possible  to  detect  gonococci  in  the 
exudate.  Bennecke  found  gonococci  only  once  in  fifty-eight  gonor- 
rhoeal  joints  in  thirty-eight  patients.  They  are  found  most  frequently 
in  the  tissues — e.  g.,  the  superficial  layers  of  the  synovial  membrane, 
and  this  explains,  perhaps,  why  they  are  so  rarely  present  in  the  exu- 
date. This  gonorrhoeal  inflammation  attacks  by  preference  the  knee 
joint,  though  the  affection  often  occurs  in  a  multiple  form  involving 
several  joints,  and  as  a  rule  is  serous  or  sero-fibrinous,  very  rarely  sup- 
purative, in  its  nature.  Quite  often  there  is  a  very  considerable  exu- 
dation into  the  joint.  In  three  hundi'ed  and  eight  cases  !Nolan  states 
that  the  knee  was  affected  eighty-six  times,  the  ankle  fifty-two,  the 
shoulder  twenty-nine,  the  wrist  twenty-six,  the  hip  fifteen,  the  fingers 
and  toes  seventeen,  etc.  Out  of  one  hundred  and  eighteen  cases,  only 
twenty-three  were  monarticular,  and  in  fifteen  cases  many  joints  were 
involved.  The  course  of  gonorrhoeal  rheumatism  in  the  majority  of 
instances  is  favourable, 
and  after  the  joint  has 
been  punctured  once  or 
twice  the  effusion  dis- 
appears entirely,  but  re- 
currences of  the  affec- 
tion are  rather  common. 
There  are  also  cases 
which  run  a  very  chron- 
ic course,  like  tumor 
albus,  arthritis  defor- 
mans, or  chronic  articu- 
lar rheumatism,  terminating  in  partial  or  conaplete  anchylosis ;  the 
severe  forms  of  the  disease  have  a  marked  tendency  to  permanent 
disturbances  of  the  mobility  of  the  joints.  There  are  also  markedly 
malignant  cases,  and  such  go  on  quickly  to  suppuration  of  the  joint 
and  soft  parts.     For  the  treatment,  see  page  693. 

The  Acute  Inflammations  of  Joints  which  occur  in  the  Course  of  Syphi- 
lis.—In  the  course  of  syphilis  there  are  likewise  observed  monarticular 
and  polyarticular  inflammations  of  joints  which  are  like  a  monarticular 
hydarthros  of  the  knee,  or,  when  polyarticular,  like  acute  rheumatism. 
The  chronic  syphilitic  inflammations  of  joints  are  discussed  in  §  114 

Gout  {Arthritis  Urica). — Gout  is  an  expression  of  the  uric-acid  dys- 
crasia.     The  blood  contains  an  excess  of  the  salts  of  uric  acid,  which 
are  deposited  especially  in  the  articular  cartilage  (Figs.  437  and  438),  the 
47 


Fig.  437. — Deposit  of  uric-acid  salts  within  the  articular  car- 
tilage of  the  knee  in  gout. 


690  INJURIES  AND   DISEASES  OF  JOINTS. 

capsule,  the  ligaments,  and  in  the  parts  surrounding  the  joints.  Ebstein, 
to  whose  painstaking  study  of  gout  we  are  greatly  indebted,  has  })ro- 
duced  the  disease  experimentally  in  cocks  by  tying  off  the  ureters  and 
destroying  the  secrethig  parenchymatous  portion  of  the  kidneys.  This 
very  painful  inflammation  occurs  in  the  form  of  paroxysms,  and  most 
commonly  attacks  the  joints  of  the  toes  {podagra),  less  often  those  of 
the  fingers  or  wrists  {chiragra),  for  the  reason  that  disturbances  of  cir- 
culation more  readily  take  place  in  the  terminal  parts  of  the  body. 
Arthritis  urica  is  mainly  a  disease  of  the  higher  classes,  and  is  more 

common  in  England  than 
on  the  Continent,  making 
its  appearance  at  the  ear- 
liest about  the  thirtieth  to 
the  thirty -fifth  year  of  life. 
Gout  begins  with  a  sei'ous 
effusion   into  the   affected 

Fig.  438.-Deposit  of  needle-shaped  crystals  of  urate  of'  .l^^i^*'  ^^^^h  is  very  apt  tO 
sodium  in  tlie  articular  cartilage  in  a  case  of  gout.  \)q  the  OUe  between  the  met- 
X  250. 

atarsus  and  first  phalanx 
of  the  great  toe.  Then  follows  the  deposition  in  and  around  the  joint 
of  crystals  consisting  of  urate  of  sodium  and  compounds  of  uric  acid 
with  calcium,  magnesium,  ammonia,  and  hippuric  acid.  The  skin  is 
very  much  reddened,  and  is  exceedingly  tender  upon  the  slightest 
pressure.  Usually  a  complete  restitutio  ad  integrum,  ensues,  but  inas- 
much as  the  attacks  are  frequently  repeated,  deforming  inflammations 
of  the  joints  may  eventually  develop,  which  consist  in  a  fibrillation  and 
abrasion  of  the  cartilage,  thickening  of  the  synovial  membrane,  peri- 
articular tissues,  etc.  There  is  also  a  formation  of  circumscribed  nod- 
ules, gout  nodes  (tophi)  as  they  are  called,  containing  chalky  deposits. 
Furthermore,  patients  with  gout  suffer  from  progressive  degenerative 
changes  in  the  internal  organs,  especially  in  the  kidneys  and  walls  of 
the  vessels  (atheroma  of  the  vessels).  The  post-mortem  examination 
of  individuals  who  have  had  this  disease  reveals  with  remarkable  fre- 
quency pulmonary  emphysema  and  chronic  interstitial  nephritis ;  also 
calcification  and  degeneration  of  the  valves  of  the  heart,  particularly 
those  of  the  aorta,  apoplexies  of  the  brain  in  consequence  of  atheroma 
of  the  walls  of  the  vessels,  etc. 

Acute  inflammations  of  joints  occurring  in  attacks  and  presenting  a 
clinical  picture  which  is  like  arthritis  urica,  are  also  sometimes  observed 
in  the  course  of  chronic  lead  poisoning. 

The  Diagnosis  of  Acute  Inflammation  of  a  Joint.— Tlie  diagnosis  of  acute 
arthritis  can  in  the  majority  of  instances  be  made  with  ease  from  the  descrip- 


§  113.]  THE  ACUTE  mFLAMMATIONS  OF  JOINTS.  691 

tion  given  above.  In  making  the  examination  the  diseased  side  should 
always  be  compared  with  the  healthy  one.  Any  exudate  which  may  be  con- 
tained in  the  joint  adapts  itself  to  the  form  of  the  latter.  A  test  puncture 
with  a  hypodermic  needle — which,  of  course,  must  be  carried  out  with  every 
antiseptic  precaution — will  give  accurate  information  as  to  the  nature  of  the 
exudate  in  the  joint,  whether  it  is  serous  or  purulent.  For  the  rest,  I  must 
refer  the  reader  to  what  we  have  said  as  regards  diagnosis  in  the  chapter  on 
Inflammation  (see  pages  252,  253). 

The  Treatment  of  Acute  Inflammation  of  a  Joint. — The  treatment  of 
acute  serous  synovitis,  acute  hydarthros,  consists,  at  the  outset,  in  main- 
taining the  part  in  a  quiet  (elevated)  position,  possibly  with  the  aid  of 
splints,  and  in  the  application  of  ice.  As  soon  as  the  inflammatory 
manifestations,  especially  the  pain,  have  subsided,  the  serous  exudate 
which  may  be  present  should  be  caused  to  disappear  by  compression 
with  elastic  bandages — the  ordinary  rubber  bandage,  for  example — and 
by  massage  practised  once  or  twice  daily,  and  the  patient  then  per- 
mitted to  walk  about.  The  treatment  by  rest  should  not  be  continued 
too  long  a  time  in  acute  hydarthros,  for  the  reason  that  the  affection 
may  then  easily  take  on  a  chronic  character. 

If  the  effusion  is  under  great  tension,  if  absorption  is  delayed,  or  if 
the  hydrops  has  become  chronic,  the  joint  should  be  punctured  aseptic- 
ally.  The  area  of  skin  over  the  joint  is  carefully  scrubbed  with  soap, 
shaved,  and  washed  with  a  five-per-cent.  solution  of  carbolic  acid  or  a 
one-tenth-per-cent.  solution  of  bichloride  of  mercury.  The  effusion  in 
the  joint  is  then  compressed  with  the  left  hand,  and  the  joint  opened 
with  a  trocar  which  has  been  sterilised  by  boiling  it  for  five  to  ten  min- 
utes in  a  one-per-cent.  solution  of  soda  (see  page  75,  Fig.  65),  or  by 
heating  it  red-hot,  or  with  a  large  hollow  needle  of  an  aspirator  simi- 
larly sterilised,  or  simply  by  puncture  or  incision  with  the  knife.  After 
the  exudate  has  been  evacuated  the  joint  can  be  washed  out  with  a 
three-per-cent.  solution  of  carbolic  or  a  one-tenth-per-cent.  solution  of 
bichloride.  In  pure  serous  effusions  I  usually  avoid  this  washing  out,  but 
do  it  if  the  effusion  is  sero-fibrinous  and  contains  flocculi  of  pus.  After 
puncturing  it  the  joint  is  immobilised  by  splints  and  an  antiseptic  dress- 
ing which  exerts  pressure.  The  aseptic  puncture  of  a  joint  with  the 
trocar,  aspirator,  or  knife  is  entirely  devoid  of  danger  if  the  rules  of 
asepsis  are  carefully  observed  and  if  pains  are  taken  to  prevent  the 
entrance  of  air  into  the  joint — in  short,  if  the  operation  is  performed 
with  the  utmost  possible  caution. 

Treatment  of  Acute  Suppurative  Arthritis. — If  there  is  pronounced 
suppuration  in  a  joint,  aseptic  puncture  followed  by  irrigation  of  the 
joint  with  a  three-per-cent.  carbolic  or  one-tenth-per-cent.  bichloride 
solution  may  be  practised  in  those  cases  in  which  the  suppuration  is 


692  INJURIES  AND  DISEASES  OF  JOINTS. 

still  in  its  inception  ;  but  if  the  suppuration  is  well  marked  and  there  is 
high  fever,  the  joint  must  be  immediately  opened  bj  a  free  incision  and 
drained  (§  31),  and,  if  necessary,  resection  of  the  joint  (§  40)  must  be 
performed.  If  the  test  puncture  (with  the  hypodermic  needle)  reveals 
acute  suppuration,  the  expectant  treatment  by  elevation,  ice,  and  immo- 
bilising dressings,  which  used  to  be  employed,  should  be  discarded,  and 
operative  treatment  by  incision  and  drainage  or  resection  should  be 
straightway  adopted  in  its  place.  Ubi  pus  ibi  evacua !  After  the 
operation  the  joint  is  placed  in  a  suitable  position  and  carefully  immo- 
bilised by  splints  and  antiseptic  dressings.  When  the  arthritis  is  sup- 
purative a  careful  examination  should  always  be  made  to  determine 
whether  periarticular  collections  of  pus  are  present.  In  cases  where 
the  suppuration  is  severe,  permanent  antiseptic  irrigation  should  be 
used  (page  181).  In  the  worst  forms  of  suppurative  arthritis  with 
putrefactive  changes  it  is  often  necessary  to  perform  an  amputation  in 
order  to  save  the  patient's  life.  If  after  suppuration  of  a  joint  recov- 
ery takes  place,  with  motion  in  the  latter,  we  improve  the  motility  as 
much  as  possible,  after  the  iniiammation  has  completely  subsided,  by 
passive  motion,  massage,  and  electricity.  If  recovery  takes  place  with 
anchylosis,  the  joint  must  be  made  to  assume  a  position  which  will  be 
as  useful  as  possible  for  the  patient.  The  ankle  and  the  elbow,  for 
example,  should  be  kept  in  a  right-angled  position,  but  the  other  joints 
must  be  extended. 

The  treatment  of  the  secondary,  metastatic  inflammations  of  joints 
is  precisely  the  same  as  for  those  which  are  primary.  If  many  joints 
are  attacked  by  suppuration,  and  there  is  a  severe  or  hopeless  constitu- 
tional disease,  one  would  probably  relinquish  all  idea  of  adopting  ener- 
getic operative  measures,  and  simply  provide  an  escape  for  the  pus  by 
incision  and  drainage,  and  alleviate  any  pain  which  the  patient  may 
suffer. 

Treatment  of  Acute  Polyarticular  Rheumatism. — Acute  polyarticular 
rheumatism  is  treated  by  immobilisation  of  the  joints  with  splints  of 
wood,  pasteboard  (see  page  224),  plaster  of  Paris,  or  water-glass ;  by 
placing  the  limb  in  an  elevated  position,  and  by  administering  internally 
diaphoretics  and  diuretics,  particularly  salicylic  acid  or  salicylate  of 
sodium  (3.0  to  6.0  grammes  j^/'o  die).  I  ordinarily  give  to  adults  four 
to  six  grammes  of  salicylate  of  sodium  in  wafers  or  a  mucilaginous 
mixture  (with  aq.  dest.  and  mucilag.  gummi.  mimos.,  aa  50.0  grammes) 
about  every  two  to  three  hours.  If  0.50  to  1.0  gramme  of  salicylic 
acid  are  given  in  wafers,  or  the  above-described  mixture,  one  should 
not  neglect  to  make  the  patient  drink  a  glass  of  water  after  each  dose, 
as  otherwise  the  stomach  may  easily  become  disordered.     I  must  refer 


§113.]  THE  ACUTE  INFLAMMATIONS  OF  JOINTS.  693 

the  reader  to  the  text-books  on  internal  medicine  for  the  rest  of  the 
treatment  of  acute  polyarticular  rheumatism,  including  any  cardiac 
complications  which  may  arise. 

Treatment  of  Gout. — The  local  treatment  of  gout  consists  in  allevi- 
ating the  pain  by  placing  the  part  in  a  proper  (elevated)  position  and 
in  enclosing  the  inflamed  joint  in  cotton  with  slight  pressure.  The 
joint  in  question  is  painted  over  with  fat  or  vaseline  and  enveloped  with 
dry  cotton,  or  a  hydropathic  dressing  is  applied  around  it.  Lithium, 
salicylate  of  sodium,  etc.,  are  given  internally.  Diaphoretic  remedies 
are  supposed  to  shorten  the  attacks.  The  patient  is  put  upon  a  light 
diet,  and  Moselle  wine  with  seltzer,  or  some  such  beverage,  is  given 
him  to  drink.  The  morbid  diathesis  is  treated  by  a  moderation  in  the 
patient's  mode  of  living,  especially  as  regards  alcohol,  by  a  meat  diet, 
which  must  not  be  too  excessive,  and  by  the  use  of  Carlsbad^  Kissin- 
gen,  Marienbad,  Wiesbaden,  Levico,  Yichy,  and  other  saline-spring 
waters  ;  the  hot  baths  of  Gastein,  Teplitz,  Wiesbaden,  etc.,  are  also 
worthy  of  recommendation. 

Treatment  of  Gonorrhceal  Rheumatism. — The  milder  cases  of  gonor- 
rhoeal  inflammations  of  joints  are  treated  by  rest  in  bed,  by  ice,  by 
immobilising  dressings,  and  by  a  simple  diet.  Ice  is  sometimes  not 
well  borne,  and  local  heat  (see  page  698)  may  have  to  be  substituted 
particularly  for  the  pain.  Balzer  recommends  warm  turpentine  baths 
from  40°-42°  C.  (104°-10r.6°  F.)  for  10-20  minutes.  From  150-800 
grammes  of  a  mixture  of  equal  parts  of  soap  and  spirits  of  turpentine 
are  added  to  each  bath.  Internally  as  much  as  4-6  grammes  of  sali- 
cylate of  sodium  may  be  given  pro  die,  or  3  grammes  of  potassium 
iodide,  which  usually  cause  a  rapid  improvement  in  the  pain  and 
inflammatory  symptoms.  In  the  case  of  large  effusions  puncture  and 
antiseptic  irrigation  of  the  joint,  as  described  above,  should  not  be  too 
long  delayed.  In  the  rare  instances  of  suppuration  of  the  joint  the 
rules  given  on  page  691  should  be  followed.  For  gonorrhceal  rheu- 
matism Yogt  recommends  the  injection  of  a  bichloride-of-mercury 
solution  into  the  joint  (0.1  gramme  bichloride,  1.0  gramme  sod.  chlor., 
and  aq.  destil.  50.0  cubic  centimetres;  three  to  five  hypodermic 
syringes  to  be  injected  into  the  joint  each  time  at  intervals  of  three 
days).  Konig  praises  injections  of  a  five-per-cent.  carbolic-acid  solu- 
tion. During  the  acute  inflammatory  stage  of  the  arthritis  the  treat- 
ment of  the  gonorrhoea  which  is  present  should  be  deferred,  but  later, 
under  all  circumstances,  it  must  be  cured  as  soon  as  possible  (see 
Regional  Surgery).  After  the  inflammation  of  the  joint  has  subsided 
it  will  often  be  advantageous  to  wear  an  elastic  bandage,  and  a  splint 
apparatus  may  possibly  be  necessary,  particularly  in  the  case  of  the 


694  INJURIES  AND   DISEASES   OF  JOINTS. 

knee,  if  the  latter  has  been  inflamed  for  some  time.  I  do  not  think 
that  massage  should  be  used  after  the  subsidence  of  a  gonorrhoea] 
arthritis,  for  the  reason  that  recurrences  of  the  affection  mav  thus  be 
lighted  up,  the  micro-organisms  being  again  introduced  into  the  circu- 
lation and  carried  off  to  other  portions  of  the  body.  I  have  seen 
rerj  satisfactory  and  permanent  cures  brought  about  in  protracted 
and  malignant  cases  from  Turkish  baths,  from  the  local  use  of  heat 
(104°-122°  F.)  and  from  life  in  southern  climates  (Riviera,  Sicily, 
Egypt,  Tunis).  Bier  recommends  the  use  of  passive  hypersemia  (com- 
bined sometimes  "with  the  local  use  of  heatj,  which  is  said  to  be  success- 
ful in  fresh  cases  as  well. 

The  symptomatology  and  treatment  of  the  acute  inflammations 
of  individual  joints  is  described  in  the  Text-Book  on  Regional 
Surgery. 

§  114.  The  Chronic  Inflammations  of  Joints. — The  chronic  inflam- 
mations of  joints  are  divided,  according  to  differences  in  pathology,  into 
two  main  groups,  namely,  the  dry  (arthritis  sicca)  and  the  exudative 
inflammations  of  joints  (arthritis  exudativa,  with  or  without  a  forma- 
tion of  new  tissue  or  of  granulations).  The  subject  of  chronic  arthritis 
is  of  very  great  practical  importance,  and,  among  others,  Billroth, 
Bonnet,  Yolkmann,  Oilier,  C.  Hueter,  and  Konig  have  done  much  to 
advance  our  knowledge  of  it. 

I.  Chronic  Serous  Synovitis  or  Arthritis  {Hydarthros,  Chronic 
Hydrops  of  a  Joint,  Chronic  Dropsy  of  a  Joint). — Hydarthros,  or 
chronic  articular  hydrops,  either  begins  very  graduall}'  as  such,  or  it 
follows  an  acute  serous  synovitis. 

The  patholog-ical  changes  aj*e  essentially  as  follows  :  The  fluid  which  col- 
lects in  the  joint  is  either  thin  and  watery,  or  it  is  thick,  gelatinous,  or  colloid. 
The  exudate  is  sometimes  remarkably  rich  in  endothelium  (Yolkmann's  endo- 
thelial catarrh).  The  secondary  changes  in  the  cartilage  and  capsule  of  the 
joint  are  usually-  slight ;  but  after  the  process  has  lasted  a  long  time  the  syno- 
vial membrane  becomes  thickened,  the  villi  ai'e  increased  in  size  and  numbers, 
the  joint  cartilage  becomes  thickened  and  fibrillated.  and  the  synovial  mem- 
brane grows  over  the  free  surfaces  of  the  cartilage  (Hueter's  synovitis  hyper- 
plastica  laevis  or  pannosa).  The  synovial  membrane  occasionally  projects 
through  the  stretched  external  fibres  of  the  capsule  in  the  form  of  a  synovial 
hernia.  After  the  hydarthros  has  existed  a  long  time  the  ligaments  and 
capsules  of  the  joint  become  stretched,  sometimes  to  such  a  degree  that  the 
joint  loses  its  normal  firmness  and  becomes  flail-like,  anddi.splacements,  sub- 
luxations, or  complete  luxations  of  the  articular  ends  of  the  bones  follow.  If 
a  rupture  of  the  capsule  of  the  joint  takes  place  spontaneously,  or  as  a  result 
of  a  traumatism,  a  periarticular  effusion  will  make  its  appearance.  The 
neighbouring  mucous  bursae  which  communicate  with  the  joint  are  often 
similarlv  diseased. 


§  114]  THE   CHRONIC   IXFLAMMATIOXS   OF   JOINTS.  695 

The  causes  of  hjdarthros  are  traumatisms  (contusions  and  sprains), 
infection,  such  as  syphilis  or  gonorrhoea,  taking  cold,  and  the  presence 
of  loose  bodies  in  the  joint. 

The  symjj>toins  are  in  the  main  the  same  as  those  of  an  acute  serous 
arthritis,  with  the  single  difference  that  inflammatory  manifestations 
are  usually  absent.  Hydarthros,  or  chronic  serous  synovitis,  most 
commonly  occurs  in  the  knee,  and  in  this  situation  the  effusion  into 
the  joint  can  best  be  demonstrated  by  placing  the  leg  in  the  extended 
position.  Yery  often,  if  the  affected  joint  is  moved,  a  creaking  and 
rubbing  can  be  felt  and  heard,  and  is  mainly  caused  by  a  thickening  of 
ihe  sjTiovial  membrane,  by  hypertrophy  of  the  villi,  together  with  an 
increase  in  their  number,  and  by  fibrillation  of  the  cartilage,  or  by  the 
formation  of  loose  joint  bodies.  The  tendency  to  the  formation  of 
free  joint  bodies  (see  §  115j  in  hydarthros  occasionally  exists  in  a 
marked  degree.  The  course  of  chronic  serous  synovitis  or  hydarthros 
is  generally  favourable  if  the  disease  receives  proper  treatment,  and 
only  in  rare  instances  do  we  meet  with  the  above-mentioned  deforming 
changes  in  the  synovial  membrane,  the  articular  cartilages,  or  in  the 
entire  articular  apparatus. 

The  best  treatment  for  chronic  serous  synovitis  consists  in  the  use 
of  massage  (see  page  520)  and  of  compression  of  the  effusion  by  means 
of  rubber  or  elastic  bandages.  It  is  of  the  utmost  importance  that  the 
patient  should  not  protect  his  joint — should  not  keep  it  quiet — but 
rather  should  use  it  industriously.  If  this  does  not  bring  about  a  cure 
and  cause  the  effusion  to  disappear,  the  latter  should  be  removed  in 
the  manner  described  above,  by  aseptic  puncture,  with  or  without  a 
subsequent  washing  out  of  the  joint  with  a  three-per-cent.  solution  of 
carbolic  acid  or  with  a  one-tenth-per-cent.  solution  of  bichloride  of 
mercury.  After  the  puncture  the  joint  must  of  course  be  immobilised 
in  a  suitable  (elevated)  position  during  the  next  few  days  by  an  anti- 
septic dressing  applied  so  as  to  exert  pressure.  If  the  reaction  follow- 
ing the  irrigation  is  too  severe,  it  should  be  combated  with  ice.  As  a 
general  thing,  simple  evacuation  of  the  effusion  by  puncture,  without 
antiseptic  irrigation,  vdll  suffice  in  the  majority  of  cases  of  hydarthros. 
A  few  days  after  removing  the  effusion  the  joint  should  be  massaged 
and  vigorously  moved,  and  from  time  to  time  enveloped  in  an  elastic 
bandage.  Any  recurrences  which  may  take  place  can  be  speedily 
cured  by  massage,  elastic  compression,  and  movement  of  the  joint. 
The  treatment  at  one  time  much  in  vogue,  by  irritation  of  the  skin 
(tinct.  of  iodine)  and  by  the  administration  of  internal  remedies  (tar- 
tar, stibiat.),  has  very  properly  been  abandoned,  and  keeping  the  joint 
quiet  is  actually  injurious.     I  never  make  use  of  the  injection  of  tine- 


696  INJURIES  AND   DISEASES  OF  JOINTS. 

tiire  of  iodine  into  tlie  joint — a  procedure  by  no  means  devoid  of  dan- 
ger. Loose  joints  caused  by  a  stretching  of  the  joint  apparatus  from 
chronic  effusions  are  treated  according  to  general  rules.  In  two  cases 
I  excised  a  portion  of  the  stretched  capsule  of  the  knee-joint,  and  made 
the  rest  of  the  capsule  smaller  by  taking  a  fold  in  it.  The  result  was 
excellent ;  in  both  cases  the  joint  became  normally  movable, 

II.  Chronic  Articular  Eheumatism  {liheuiiiatisinus  Chronicus  Ar- 
ticuloynim,  Polyarthritis  Rhewmatica  Chronica). — By  chronic  articular 
rheumatism  we  understand  an  inflammation  of  the  synovial  membrane 
running  an  exceedingly  slow  course,  which  occurs  almost  exclusively 
in  adults,  generally  after  the  thirtieth  to  the  fortieth  year,  and  always 
attacks  several  joints.  There  is  generally  a  gradually  increasing  dis- 
turbance in  the  function  of  the  joints,  which  ordinarily  in  the  end  leads 
to  complete  stiffness  or  anchylosis  of  the  joint.  In  exceptional  cases 
chronic  polyarticular  rheumatism  has  been  observed  in  children  and 
young  adults. 

Etiology  of  Chronic  Articular  Rheumatism.— The  etiology  of  chronic 
articular  rheumatism  is  varied.  Joint  inflammations  with  very  different 
causes  can  run  a  course  like  chronic  rheumatism.  The  real  cause  of  chronic 
rheumatism  is  unknown  ;  it  has  nothing  to  do  with  acute  articular  rheuma- 
tism, does  not  become  complicated  by  cardiac  affections,  and  is  not  influ- 
enced by  the  salicj^lic  preparations.  Among  predisposing  factors  may  be 
mentioned  catching  cold,  being  wet  through,  damp  dwellings,  poverty,  nerv- 
ous exhaustion,  and  previous  joint  affections.  The  disease  almost  always 
attaclcs  adults,  and  only  exceptionally  are  severe  cases  observed  in  chil- 
dren with  deformities  of  the  joints,  as  in  arthritis  deformans.  It  has  not 
yet  been  proved  that  the  disease  has  a  genetic  connection  with  organic  or 
functional  diseases  of  the  nervous  system,  so  that  it  could  be  regarded  as  a 
central  or  reflex  tropho-neurosis.  As  in  the  case  of  acute  articular  rheuma- 
tism, the  part  played  by  micro-organisms  in  the  etiology  of  the  disease 
has  not  yet  been  made  sufficiently  clear.  Schiiller  found  in  chronic  rheu- 
matic joint  inflammations  with  the  development  of  villi,  but  without  suppu- 
ration, short  thick  bacilli,  which  could  be  cultivated  best  at  25°  C,  and  in 
the  dark  ;  by  inoculating  rabbits  a  characteristic  clinical  picture  of  the  dis- 
ease is  said  to  have  been  produced.  In  my  opinion,  the  majority  of  cases  of 
chronic  articular  rheumatism  are  due  to  bacterial  infection.  Gonorrhoea  is 
sometimes  a  cause  (see  page  688,  Gonorrhoeal  Arthritis).  Chi'onic  articular 
rheumatism  occurring  later  in  life  seems  to  be  related  to  arterio-sclerosis, 
and  in  such  case  might  be  regarded  as  a  disturbance  of  nutrition  in  the  joint. 
Judging  from  the  very  chronic  course  of  the  disease,  it  seems  possible  that 
there  may  be  several  causes  or  different  kinds  of  infection  which  act  at  one 
time  or  successively. 

The  anatomical  changes  which  occur  in  chronic  articular  rheuma- 
tism consist  essentially  in  a  chronic  inflammatory  formation  of  new 
connective  tissue  in  the  synovial   membrane   and   surrounding  parts 


§114.]  THE  CHRONIC  INFLAMMATIONS  OF  JOINTS.  69T 

which  have  a  tendency  to  shrink  and  become  hard  and  dense,  in  a 
fibrillation  of  the  cartilage,  and  in  a  substitution  for  the  latter  of  vascu- 
lar connective  tissue.  The  connective-tissue  metaplasia  of  the  cartilage 
is  brought  about  mainly  by  growth  on  the  part  of  the  synovial  mem- 
brane, though  it  is  very  largely  promoted  by  the  increased  formation 
of  medullary  spaces  in  the  deeper  layers  of  cartilage,  and  by  inflamma- 
tory changes  with  a  formation  of  new  vessels  in  the  subchondral 
medulla.  As  the  new  formation  of  connective  tissue  increases,  the 
cavity  of  the  joint  grows  steadily  smaller.  The  stifEness  of  the  joint, 
the  anchylosis,  is  at  the  outset  due  to  connective-tissue  adhesions  which 
may  eventually  ossify,  the  process  spreading  from  the  spongiosa  until 
the  entire  joint  may  become  filled  with  bone.  Chronic  articular  rheu- 
matism never  leads  to  suppuration,  and  never  to  true  caries,  the  patho- 
logical changes  presenting  more  of  a  similarity  to  arthritis  deformans, 
except  that  in  the  latter  disease  there  is  more  an  increased  growth  of 
cartilage,  while  in  the  former  the  cartilage  is  replaced  by  vascular  con- 
nective tissue.  But  deformities  of  the  joints,  subluxations,  and  luxa- 
tions develop  in  chronic  articular  rheumatism  as  they  do  in  arthritis 
deformans. 

Chronic  articular  rheumatism  either  follows  an  acute  rheumatism, 
or  it  begins  insidiously  as  a  chronic  disease  which  lasts  many  years,  and 
is  very  frequently — in  fact,  as  a  rule — incurable.  Gradually  many 
difierent  joints  become  affected,  and,  in  rare  instances,  all  the  joints  of 
the  body. 

The  subjective  symptoms  consist  in  sharp,  severe  pains  felt  now  in 
this  and  now  in  that  joint.  The  movements  of  the  joints,  particularly 
in  the  morning,  after  the  night's  rest,  are  limited  and  cause  pain ;  but 
during  the  day,  after  the  patient  has  used  his  limbs  somewhat,  the 
mobility  of  the  joints  improves.  In  other  instances  the  joints  are  so 
painful  that  no  movements  at  all  can  be  performed.  The  joints  are 
usually  somewhat  swollen ;  and  in  many  cases — i.  e.,  in  the  so-called 
fungous  form  of  articular  rheumatism — the  growth  of  connective  tissue 
is  so  considerable  that  the  joints  present  the  appearance  of  tumor 
albus.  If  the  joints  are  moved,  a  creaking  or  crackling  friction  sound, 
due  to  the  newly  formed  connective  tissue  and  to  the  fibrillation  of 
the  cartilage,  can  very  frequently  be  made  out.  As  a  rule,  subacute 
exacerbations  of  the  subjective  and  objective  symptoms  take  place  at 
irregular  intervals,  the  joints  become  steadily  stiffer,  and  the  muscles 
atrophy  more  and  more,  so  that  these  pitiable  individuals  grow  con- 
stantly more  helpless,  and  death  often  occurs  from  general  marasmus 
or  some  intercurrent  disease.  In  other  cases  the  process  comes  to  a 
standstill  with  partial    or   total  anchylosis  of   the   affected  joints.     I 


69S  INJURIES  AND   DISEASES  OF  JOINTS. 

saw  a  divinity  student,  forty  years  of  age,  who  had  complete  anchy- 
losis of  both  hips,  both  knees,  the  right  elbow,  and  the  left  wrist; 
and  Percy  found  anchylosis  of  all  the  joints  of  the  body  in  a  French 
officer  who  died  in  his  fiftieth  year.  The  skeleton  of  this  officer,  who 
had  suffered  from  chronic  articular  rheumatism  contracted  in  his  cam- 
paigns, has  been  jjreserved  in  the  Ecole  de  Medecine,  and  forms,  to 
all  appearances,  a  single  piece  of  bone. 

The  diagnosis  of  chronic  polyarticular  rheumatism  can,  in  all 
probability,  be  readily  made  from  what  has  been  said  above ;  but 
the  milder  cases  are  often  difficult  to  dilfei-entiate  from  gout  and 
arthritis  deformans.  TVe  have  also  made  the  prognosis  sufficiently 
clear. 

The  treatment  of  chronic  polyarticular  rheumatism  generally  de- 
mands a  great  deal  of  patience,  and  even  then,  I  am  sorry  to  say,  is 
often  entirely  unsuccessful.  In  cases  which  are  not  of  long  standing, 
massage  and  methodical  exercise  of  the  joints  should  1)6  tried  in  com- 
bination with  hydrotherapy  (baths,  steaming,  douches,  etc.).  The  joint 
should  not  be  kept  quiet  in  the  early  stages  of  a  chronic  rheumatism. 
If  massage  and  movement  of  the  joint  are  too  painful,  they  must  be 
carried  out  occasionally  under  chloroform  anaesthesia.  I  have  seen 
very  satisfactory  and  permanent  cures  obtained  by  this  treatment  in 
cases  which  had  not  existed  too  long  a  time.  Furthermore,  hot 
springs,  such  as  Gastein,  Teplitz,  Wiesbaden,  Wild  bad,  and  Ragatz- 
Pfiiffers,  a  residence  in  warm  climates,  and  particularly  the  use  from 
time  to  time  of  local  heat,  are  very  valuable.  Heat  may  be  employed 
in  the  form  of  hot  air,  steam,  packs,  etc.  Internall}-,  cod-liver  oil  and 
iron,  potassium  iodide,  or  vinnm  colchici  seminis  have  been  recom- 
mended ;  the  use  from  time  to  time  of  the  salicylates  is  very  service- 
able. But  often,  on  account  of  the  severe  pain,  massage  cannot  be 
carried  out,  or  the  joints  may  already  have  undergone  too  extensive 
changes.  In  such  cases,  which  are  generally  of  long  standing,  we  are 
often  compelled  to  confine  ourselves  to  orthopaedic  treatment,  placing 
the  diseased  joints  in  a  good  jsosition,  under  chloroform  anaesthesia, 
and  immobilising  them  by  plaster-of-Paris  splints.  As  a  result  of  the 
rest  given  the  joints  by  the  plaster  of  Paris,  the  pain  ordinarily  becomes 
less,  but  at  the  same  time  the  occurrence  of  anchylosis  is  favoured. 
After  having  kept  the  diseased  joints  quiet  by  splints  for  a  long  time, 
it  has  been  my  expei-ience  that  all  hopes  of  the  possibility  of  oljtaining 
a  cure  with  a  movable  joint  must  generally  be  given  up,  and  a  recovery 
with  anchylosis  be  striven  for.  Sonnenburg,  Miiller,  and  others  have 
recently  obtained  good  results  from  operative  ti'eatment,  consisting 
either  in  arthrotomy  and  antiseptic  irrigation,  with  or  without  drain- 


§  114.]  THE  CHRONIC  INFLAMMATIONS  OF  JOINTS.  699 

age,  sjnovectomy,  and,  in  rare  cases,  in  resection.  Schiiller  recom- 
mends injections  of  sterilised  iodoform-glycerine-guaiacol  (ten  to  fifteen 
grammes  of  a  mixture  of  five  grammes  of  iodoform  to  sixty  to  one 
hundred  grammes  of  glycerine  and  twenty  drops  of  purified  guaiacol). 
I  have  not  seen  any  success  from  intra-articular  injections  in  chronic 
rheumatism,  but  I  believe,  vdth  Sonnenburg  and  Schiiller,  that  chronic 
articular  rheumatism  in  its  later  stages,  especially  if  there  is  great  pain, 
should  receive  operative  treatment  more  frequently  and  earlier  than  it 
ordinarily  does. 

III.  Chronic  Suppuration  of  Joints. — Every  suppuration  of  a  joint  is 
the  result  of  infection  by  micro-organisms.  The  infection  takes  place 
in  conjunction  with  a  traumatism,  for  example,  or  by  way  of  the  cir- 
culation, or  in  consequence  of  the  extension  to  the  joint  of  a  suppura- 
tive inflammation  in  the  surrounding  parts  (medulla,  periosteum,  soft 
parts).  In  chronic  suppuration  of  a  joint  the  synovial  membrane  is 
usually  the  seat  of  an  inflammatory  infiltration  and  is  covered  with 
fibro-purulent  masses,  the  cartilage  is  cloudy  and  fibrillated,  and  losses 
of  substance  develop  in  it  (cartilage  ulcers) ;  occasionally  large  portions 
of  the  cartilage  necrose  and  separate  from  the  underlying  parts,  or  the 
cartilage  is  completely  destroyed.  The  suppuration  very  often  spreads 
to  the  medulla,  the  periosteum,  and  the  periarticular  tissues.  The  joint 
becomes  more  or  less  altered  according  to  the  severity  and  duration  of 
the  suppuration,  and  in  pronounced  cases  which  have  existed  for  a 
long  time  fibrous  or  bony  anchylosis  usually  develops  when  recovery 
takes  place,  as  we  remarked  before  in  discussing  the  subject  of  acute 
suppurative  arthritis. 

We  shall  first  take  up  that  form  of  chronic  suppuration  of  joints 
which  is  due  to  tuberculosis. 

TV.  The  Chronic  Fungous  and  Suppurative  (Tubercular)  Inflammations 
of  Joints— Tuberculosis  of  Joints — Tumor  Albus — Tubercular  Caries  of 
Joints — Fungus  of  Joints. — All  these  terms  indicate  one  and  the  same 
disease,  viz.,  tuberculosis  of  joints  or  tubercular  arthritis. 

Tubercular  arthritis  either  begins  primarily  in  the  syno\dal  mem- 
brane or  it  is  secondary  to  tubercular  foci  in  the  bone.  Miiller's 
statistics,  obtained  from  Konig's  clinic,  show  that  in  two  hundred  and 
thirty-two  cases  of  tubercular  arthritis  one  hundred  and  fifty-eight 
started  in  the  bones,  forty-six  in  the  synovial  membrane,  and  in 
twenty-eight  cases  the  point  of  origin  was  uncertain.  We  remarked 
on  page  634  that  the  anatomical  structure  of  the  medulla  is  especially 
favourable  to  a  deposition  from  the  blood  of  the  tubercle  bacilli,  and 
we  likewise  emphasised  the  fact  that  tubercular  arthritis  develops  very 
often  after  the  reception  of  some  traumatism.     Later  investigations 


700 


INJURIES  AND   DISEASES   OF  JOINTS. 


have  led  Konig  to  conclude  that  the  primary  form,  beginning  in  the 
synovial  membrane,  is  more  common  than  the  one  secondary  to  disease 
of  the  bone.  I  agree  with  him  fully.  The  general  subject  of  tuber- 
culosis and  of  tuberculosis  of  bone  is  described  in  §  83  and  §  105,  and 
therefore  we  shall  confine  ourselves  here  to  the  presentation  of  the 
tuberculosis  involving  joints. 

The  Pathological  Changes  which  Occur  in  Tubercular  Arthritis.— The 

pathological  changes  which  occur  when  a  joiut  is  infected  by  tubercle  bacilli, 
no  matter  whether  the  iufection  is  primary  in  the  joint  or  secondary  to  simi- 
lar disease  in  the  medulla,  periosteum,  or  periarticular  soft  parts,  are  as  fol- 
lows :  The  bacilli  enter  by  one  or  more  points  of  infection,  and  are,  so  to 
speak,  planted  in  different  parts  of  tlie  joint,  where  they  give  rise  to  the 


Fig.  439. — Largv  infarct-shaped  subchondral 
tubercular  focus  in  the  head  of  the  femur, 
which  is  in  an  advanced  stage  of  demarca- 
tion; the  articular  cartilage  is  lifted  up 
like  a  pustule.  Early  resection.  Five- 
year-old  girl.     Cure. 


Fig.  440.— Tuberculosis  of  the  neck  of  tlie 
femur  with  three  sequestra.  Secondary 
tuberculosis  of  the  hip-joint ;  the  cartilage 
of  the  head  of  the  femur  is  destroyed. 
Eesection  of  the  hip.  Eight-year-old  boy 
(Volkmann). 


development  of  tubercles  which  have  the  structure  that  we  described  on  a 
previous  page  (115).  The  synovial  membrane  undergoes  inflammatory 
changes  and  is  filled  with  characteristic  greyish-white  nodules,  and  as  the 
tuberculosis  advances  it  is  possible  to  distingui-sh  three  different  forms  of 
the  disease,  which,  to  be  sure,  merge  into  one  another :  (1)  the  pure  miliary 
form,  without  the  formation  of  a  spongy,  so-called  fungous  tissue,  (2)  the 
fungous  form,  and  (3)  the  fibrous,  with  the  formation  of  lardaceous  thick- 
enings. The  fungous  form  of  tubercular  arthritis  is  the  most  common,  and 
in  it  the  synovial  membrane  becomes  changed  into  a  .spongy,  red  granula- 
tion tissue  filled  with  tubercles,  while  during  the  early  stages  the  joint  con- 
tains a  serous  or  sero-flbrinous  exudate  (hydrops  tuberculosus),  and  later  on 
pus  in  which  there  are  generally  small  particles  of  cheesy  matter  (cold, 
tubercular,  suppurative  arthritis).  According  to  Konig  this  sero-fibrinous 
effusion  is  the  first  symptom  within  the  joint,  both  in  the  form  that  starts  in 
the  bone  and  the  one  that  is  primary  in  the  synovial  membrane.  Rice 
bodies  are  usually  formed  in  tubercular  joints,  and  are  due  mainly  to  a 


114.] 


THE   CHEONIC  INFLAMMATIONS   OF  JOINTS. 


YOl 


Fig.  441.— So-called  "wandering  of  the 
acetabulum  "  in  coxitis  ("  iutra-acetab- 
ular  dislocation  "). 


fibrinoid  degeneration  (coagulation  necrosis)  of  the  synovial  fluid  (see  page  579 
and  page  581).  The  tubercular  granulation  tissue  in  course  of  time  grows  into 
all  parts  of  the  joint,  pushes  its  way  over 
the  cartilage  and  ligaments,  and  pene- 
trates into  the  bone  and  medulla,  etc. ;  in 
short,  wherever  the  tubercular  granula- 
tion tissue  develops  the  original  tissue  is 
destroyed.  In  the  case  of  tuberculosis  of 
bone  the  portion  of  the  latter  which  is 
affected  by  the  disease  either  necroses  in 
toto  (Fig.  439),  or  several  isolated  seques- 
tra are  formed  (Fig.  440).  In  the  caput 
femoris,  for  example,  very  cliaracteristic 
cuneiform  sequestra  are  frequently  ob- 
served (Fig.  439)  which  are  similar  to  the 
so-called  infai'cts — i.  e.,  the  necrosis  of  tis- 
sue resulting  from  occlusion  of  the  termi- 
nal, afferent  arterial  vessel.  These  in- 
farcts have  the  form  of  a  wedge  which 

corresponds  to  the  distribution  of  the  terminal  branches  of  the  affected  ves- 
sels. The  cuneiform  sequestra  w^hich  are 
met  with  in  tuberculosis  of  bone  are  prob- 
ably due  in  the  same  way  to  the  plugging 
of  the  terminal  artery  at  the  apex  of  the 
wedge  with  tubercle  bacilli.  If  the  tuber- 
culosis begins  in  the  bone  the  articular 
cartilage  either  becomes  perforated  like  a 
sieve  by  the  tubercular  inflammation,  or 
it  is  raised  from  the  underlying  parts  more 
or  less  in  toto,  as  in  Fig.  439.  In  the  later 
stages  large  portions  of  articular  cartilage 
may  be  separated  in  toto  from  the  bone, 
or  the  cartilage  may  be  completely  de- 
stroyed, as  in  Fig.  440.  It  is  very  fortu- 
nate for  the  patient  if  the  tubercular  pro- 
cess, for  example,  in  the  epiphysis  of  a 
long,  hollow  bone  does  not  attack  the 
joint  but  breaks  through  externally  to  it. 
This  extra-articular  breaking  through  of 
bone  tuberculosis  in  the  neighbourhood 
of  a  joint  is  a  rather  common  occurrence. 
After  the  tubercular  inflammation  of  the 
joint  has  broken  through  the  joint  capsule 
there  follows  a  development  of  periarticu- 
lar tuberciilar  inflammation  and  suppura- 
tion with  extensive  collections  of  pus — the 
so-called  congestion,  cold,  or  gravitation 
abscesses  which  we  have  spoken  of  in  a  previous  chapter.  Not  infrequently 
the  extra-articular  tubercular  abscesses  originate  by  infection  through  the 


Fig. 


442. — Tubercular  kyphosis   of 
spine  in  a  boy  of  twelve. 


the 


702 


INJURIES  AND  DISEASES  OF  JOINTS. 


lymph  channels  without  a  rupture  of  the  capsule  having  taken  place,  and 
without  the  existence  of  any  visible  communication  between  the  intra-  and 
extra-articular  suppurative  processes.  If  the  lymph  glands  connected  with 
the  joint  become  infected  by  tuberculosis,  the  danger  of  the  tubercle  bacilli 
being  carried  further— in  other  words,  the  danger  of  a  general  tuberculosis- 
becomes  more  imminent.     Very  often  the  tubercular  inflammation  works  its 

way  outwards  through  the  skin  sponta- 
neously, and  gives  rise  to  fistuko  which 
frequently  pass  a  long  distance  through 
soft  parts  and  bone. 

The  destruction  of  tissue  which  takes 
place  in  tubercular  arthritis,  and  is  the 
result  of  the  progressive  change  of  bone, 
cartilage,  and  soft  parts  into  tubercular 
granulation  tissue,  which  breaks  down 
and  undergoes  cheesy  degeneration  and 
suppuration,  is  sometimes  very  consider- 
able. The  entire  head  and  neck  of  the 
femur  may  thus  be  destroyed  by  caries 
and  necrosis,  and  not  infrequently  exten- 
sive ulcerative  processes  lead  to  perfora- 
tion of  the  acetabulum.  Very  often  the 
latter  becomes  enlarged  in  an  upward  di- 
rection, and  the  head  of  the  femur,  fol- 
lowing the  change  in  the  shape  of  the 
acetabulum,  is  caused  to  assume  a  higher 
position — a  phenomenon  which  is  called 
"  wandering  of  the  acetabulum "  (Fig. 
441).  In  the  sj)inal  column  entire  verte- 
brae may  be  destroyed,  giving  rise  to  cor- 
responding deformities,  especially  kypho- 
sis or  Pott's  hump  (Fig.  442).  Further- 
more, in  tuberculosis  of  the  vertebrae,  the 
cold,  congestion  abscesses  which  gradu- 
ally burrow  downwards  may  attain  a  con- 
siderable size ;  they  usually  follow  the  course  of  the  ilio-psoas  muscle,  and 
may  eventually  come  to  the  surface  in  the  thigh  beneath  Poupart's  ligament. 
If  left  to  itself  a  tubercular  focus  may  heal  up  at  any  stage  of  its  exist- 
ence. Recovery  often  takes  place  only  after  the  joint  has  become  com- 
pletely obliterated  or  anchylosed,  but  not  infrequently  the  cure  is  only 
apparent  and  temj)orary.  If  the  joint  has  not  been  immobilised  in  a  j^roper 
position  while  the  tubercular  disease  Avas  in  progress,  contractures  are  very 
liable  to  take  place  ;  and  if  these  affect  the  knee  or  hi^J,  the  use  of  the  leg  may 
be  seriously  interfered  with  or  rendered  impossible  fsee  Fig.  443). 

The  Development  of  Tubercular  Arthritis  after  the  Injection  of  Tubercle 
Bacilli  into  the  Joints  of  Animals.— If  pure  cultures  of  tubercle  bacilli  are 
injected  into  the  joints  of  guinea-pigs  there  will  be  observed,  after  the  lapse 
of  four  to  six  days,  an  increasing  inflammatory  swelling  and  exudation  into 
the  joints  under  consideration,  and  towards  the  end  of  the  third  week  the 


Fig.  443. — Tubercular  contracture  and  an- 
chylosis of  the  knee  in  a  six-year-old 
boy.  Cuneiform  resection  followed  by 
healing  in  the  extended  position. 


§  114.]  THE  CHRONIC  INFLAMMATIONS  OF  JOINTS.  703 

presence  of  tubercle  bacilli  can  be  plainly  made  out,  and  pus  will  be  found  in 
the  joints.  Pawlowsky  states  that  the  tubercle  bacilli  are  located  mainly  in 
the  lymph  passages  and  connective-tissue  cells.  If  intravenous  injections  of 
attenuated  (weakened)  cultures  of  tubercle  bacilli  are  practised  in  rabbits, 
the  typical  picture  of  tubercular  disease  of  joints  will  sometimes  be  obtained 
only  after  four  to  five  to  six  months,  while  the  other  organs  will  remain 
healthy  (Courmont,  L.  Dor). 

Tubercular  arthritis  runs  an  exceedingly  chronic  course,  as  a  rule, 
and  often  lasts  many  years.  The  disease  most  commonly  attacks  chil- 
dren, though  adults  of  all  ages  are  not  exempt  from  it.  The  joints 
most  frequently  affected  are  the  knee,  the  hip,  the  astragalo-tibial 
joint,  and  the  joints  of  the  tarsus.  Tubercular  arthritis  generally 
begins  very  gradually,  but  in  rare  instances  is  more  or  less  acute  in  it& 
onset.  Yery  acute  cases  are  sometimes  observed  in  young  children 
from  one  to  two  years  of  age,  in  which  considerable  pus  is  formed, 
with  cellulitis  of  the  soft  parts  and  a  rise  of  temperature.  The  pus 
contains  tubercle  bacilli.  The  prognosis  of  these  cases  is  usually 
good  if  the  pus  is  evacuated  promptly,  and  they  are  often  cured  by 
a  simple  arthrotomy,  just  like  tubercular  peritonitis.  If  we  leave  out 
of  consideration  this  special  form,  the  course  of  tubercular  arthritis  is 
usually  as  follows :  The  first  symptoms  of  tuberculosis  involving  the 
knee-joint  of  a  child,  for  example,  are  a  proneness  to  fatigue  and  a 
slight  limp  or  dragging  of  the  leg  in  walking.  After  walking  for 
some  time,  or  if  pressure  is  made  on  the  joint,  the  child  complains 
of  pain.  The  first  objective  symptom  is  generally  a  moderate 
amount  of  swelling,  which  causes  the  furrows  beside  the  patella  to 
become  less  plainly  marked  than  upon  a  healthy  knee.  The  initial 
symptoms  manifested  by  joints  which  are  more  deeply  placed  are  not 
so  apparent  as  they  are  in  the  knee.  As  the  disease  progresses  the 
swelling  of  the  knee  gradually  increases,  and  the  normal  contour  of  the 
joint  disappears  to  a  greater  and  greater  extent.  The  swelling  feels 
rather  hard,  or  it  is  more  soft  and  spongy,  and  is  caused  either  by  a 
thickening  of  the  synovial  membrane  and  periarticular  connective 
tissue,  or,  as  in  primary  osseous  tuberculosis,  by  enlargement  of  the 
articular  ends  of  the  bones.  The  skin  is  ordinarily  more  or  less  tense, 
and  presents  a  white,  waxy  appearance,  which  gave  rise  to  the  term 
tumor  albus,  formerly  used  to  designate  this  condition.  As  the  swell- 
ing becomes  greater  the  pain  in  the  joint  increases,  and  is  made  worse 
by  pressure  and  attempts  at  motion.  The  pain,  however,  is  not  always 
felt  in  the  diseased  joint,  as  in  tubercular  inflammation  of  the  hip 
(coxitis),  for  example,  the  children  very  often  complain  of  pain  in  the 
knee,  which  might  lead  an  inexperienced  person  to  search  for  the  dis- 


704  INJURIES  AND   DISEASES  OF  JOINTS. 

ease  in  the  wrong  place.  Tins  pain  in  the  knee  accompanying  tuber- 
cular coxitis  is  particularly  apt  to  be  present  when  there  is  tubercular 
disease  of  the  medulla,  the  pain  shooting  through  the  latter  down  to 
the  lower  epiphysis  ;  the  phenomenon  used  to  be  looked  upon  as  a  reflex 
manifestation.  Standing  and  walking  eventually  become  impossible, 
and  the  tubercular  inflammation  causes  the  joint  to  grow  more  and 
more  immovable.  The  knee  and  elbow  are  usually  flexed  to  a  greater 
or  less  extent,  and  the  hip  assumes  a  position  of  flexion,  abduction, 
and  outward  rotation.  At  the  outset  the  abnormal  position  of  the 
joints  can  be  corrected  under  chloroform  anaesthesia,  but  later  this 
cannot  be  accomplished  without  operative  interference.  The  distorted 
positions  of  the  joints — the  contractures — may  sometimes,  as  a  result 
of  improper  treatment,  become  very  excessive,  as  illustrated  in  Fig. 
4-13  ;  but  contractures  like  this  can  always  be  easily  prevented  by  the 
use  of  retentive  dressings  applied  at  the  right  time. 

Attempts  have  been  made  to  explain  this  abnormal  position  as- 
sumed by  inflamed  joints  by  (1)  the  mechanical  theory  advanced  by 
Bonnet,  and  (2)  by  the  reflex  theory.  Bonnet  demonstrated  by  intra- 
articular injection  of  a  liquid  that  the  joint  thus  treated  assumes  a 
position  in  which  its  capacity  is  greatest — i.  e.,  increasing  its  contents 
forces  a  joint  like  the  knee  to  become  flexed.  According  to  the  second 
theory,  a  reflex  muscular  contracture  is  produced  by  the  irritation  of 
the  synovial  membrane.  Both  theories  are  right  as  far  as  they  go,  but 
by  themselves  are  not  suflicient  to  answer  the  question — a  fact  which 
Yolkmann  has  correctly  insisted  upon.  It  must  be  borne  in  mind  that 
the  patient  instinctively  places  his  joint  in  a  position  which  diminishes 
the  pressure  on  the  joint  surfaces  and  causes  him  the  least  pain.  More- 
over, the  mechanical  conditions  connected  with  the  use  of  the  diseased 
extremity,  the  longitudinal  growth  of  the  bone,  and  subsequently  the 
changes  which  take  place  in  the  shape  of  the  articular  ends  of  the 
bones,  have  an  influence  upon  contractures  (see  pages  569  and  575). 

The  further  course  of  tubercular  arthritis — sometimes  called  the 
second  stage  of  the  affection — is  characterised  by  an  increase  of  all  the 
pre-existing  symptoms,  especially  the  swelling,  fixation,  and  pain,  and, 
in  addition,  there  are  very  often  manifestations  of  suppuration  in  the 
joint;  in  other  words,  fever  develops,  the  joint  becomes  very  pain- 
ful at  some  particular  point,  and,  finally,  fluctuation  can  be  detected. 
Suppuration  in  the  joint  is  either  accompanied  by  inflammatory  mani- 
festations of  variable  intensity,  or  it  runs  its  course  as  a  cold  abscess. 
The  amount  of  pus  which  is  present  is  by  no  means  constant,  being  in 
some  instances  very  considerable,  while  in  others  the  formation  of  pus 
is  slight,  although  the  destruction  of  the  articular  ends  of  the  bones 


§114.]  THE  CHRONIC  INFLAMMATIONS  OP  JOINTS.  705 

may  be  very  marked.  Permanent  deformities  develop  in  consequence 
of  these  changes  in  the  bones,  as  well  as  the  so-called  pathological  or 
spontaneous  dislocations.  The  anatomical  changes  which  follow  sup- 
puration in  a  joint,  the  development  of  periarticular  abscesses  from 
rupture  of  the  pus  in  the  joint  through  the  capsule  or  from  infec- 
tion through  the  lymphatics,  the  occurrence  of  extensive  gravitation 
abcesses,  etc.,  have  all  been  described  above. 

The  patients'  general  condition  is  ordinarily  very  much  altered  for 
the  worse  ;  they  are  emaciated,  anaemic,  without  appetite,  and  not  infre- 
quently have  diarrhoea  and  more  or  less  fever. 

Tubercular  arthritis  terminates  either  in  recovery,  or  in  death  from 
systemic  tubercular  infection,  from  tuberculosis  of  the  internal  organs, 
€specially  the  lungs  and  intestine,  from  increasing  marasmus,  from 
amyloid  degeneration,  or  from  some  intercurrent  disease.  Tubercu- 
losis is  the  most  common  cause  of  death.  Of  one  hundred  and  thirty- 
:five  cases  of  tubercular  arthritis  which  ended  fatally,  Albrecht  states 
that  sixty -four  were  due  to  tuberculosis,  twenty- three  to  marasmus, 
and  fourteen  to  amyloid  changes;  while  in  thirty-four  the  cause  of 
death  was  unknown.  Billroth  maintains  that  the  danger  of  pulmonary 
tuberculosis  is  greater  after  tubercular  arthritis  occurring  in  the  upper 
extremity  than  when  the  disease  affects  the  lower. 

As  a  general  thing  it  requires  a  very  long  time,  often  years,  for 
recovery  to  take  place  spontaneously  from  tubercular  arthritis.  In 
such  cases  there  is  a  gradual  abatement  of  the  local  manifestations,  the 
general  health  improves,  and  any  fistulse  which  may  be  present  close 
up.  When  spontaneous  recovery  takes  place  from  a  pronounced  tuber- 
cular arthritis  with  fistulse,  the  joint  which  has  been  affected  always 
l)ecomes  stiff.  If  no  appreciable  suppuration  has  occurred,  recovery 
not  infrequently  follows  without  operative  interference  and  with  per- 
fect motion  in  the  joint  in  question.  It  is  scarcely  possible  to  say 
with  certainty  when  joints  which  have  been  affected  by  tuberculosis 
liave  become  entirely  well,  for  relapses  have  taken  place  even  after 
anchylosis  has  existed  for  years.  With  the  modern  methods  of  per- 
forming surgical  operations  we  are  able  to  give  a  more  favourable 
prognosis,  both  as  regards  the  preservation  of  the  joint  and  the  life  of 
the  patient.  ]Srevertheless,  the  prognosis  of  tubercular  arthritis,  as  Bill- 
roth has  remarked,  is  in  so  far  unfavourable,  as  such  individuals  do  not 
reach  an  advanced  age.  There  are,  for  example,  only  comparatively 
few  people  with  anchylosis  due  to  tuberculosis  who  live  to  be  more 
than  forty  or  fifty  years  old,  and  only  the  minority  of  children  who 
have  been  operated  upon  for  tubercular  caries  of  a  joint,  and  cured, 
attain  adolescence. 

48 


Y06  INJURIES  AND  DISEASES  OF  JOINTS. 

Treatment  of  Tubercular  Arthritis. — Tlie  tlierapy  of  tubercular  ar- 
thritis comprises  local  treatment  of  the  diseased  joint,  and  measures 
designed  to  improve  the  general  health  and  render  the  system  capable 
of  successfully  carrying  on  the  struggle  for  existence  with  the  tubercle 
bacilli.  This  constitutional  treatment  is  described  on  pages  431  and 
434  (Constitutional  Treatment  of  Tul)erculosis  and  Scrofula), 

Inasmuch  as  tubercular  arthritis  gets  well,  though  very  slowly, 
under  proper  local  and  constitutional  treatment  without  operative 
interference,  it  would  be  entirely  wrong  to  immediately  subject  every 
ease  of  tuberculosis  of  joints  to  operation.  Therefore,  at  the  begin- 
ning; of  the  tubercular  arthritis  the  local  treatment  should  be  directed 
towards  securing  absolute  rest  for  the  joint  by  means  of  hardening 
dressings  (see  §  54,  plaster  of  Paris,  water-glass),  or  some  of  the  vari- 
ous kinds  of  splints  (see  §  53),  or  by  permanent  extension  (see  §  55), 
the  latter  being  particularly  applicable  for  the  hip.  Sayre  and  Taylor 
have  invented  ingenious  extension  appliances  for  the  lower  extremity 
which  enable  the  patient  to  walk  about.  It  is  also  very  advantageous 
in  the  case  of  coxitis  to  place  a  raised  sole  under  the  foot  of  the  sound 
side,  and,  by  using  crutches  to  walk  with,  thus  keep  in  suspension 
the  diseased  leg,  which  should  be  maintained  in  a  fiied  position  by 
a  Thomas  splint  (see  Regional  Surgery,  YoL  III,  page  715).  Hydro- 
pathic applications  or  ice  may  also  be  employed  for  acute  or  subacute 
exacerbations  which  are  accompanied  by  pain.  If  contractures  of  the 
joints  are  already  present  when  the  case  comes  under  observation,  they 
must  be  gradually  overcome  by  retentive  (see  page  220)  or  extension 
dressings,  often  with  the  aid  of  chloroform  ansesthesia.  Great  care 
must  be  taken  in  correcting  the  position  of  a  joint  which  has  become 
distorted ;  it  will  often  be  impossible  to  remedy  matters  all  at  once, 
and  the  desired  result  will  have  to  be  accomplished  gradually  in  several 
sittings.  Each  time  that  the  contracture  is  improved  the  joint  should 
be  immediately  fixed  in  its  new  position  by  a  plaster-of-Paris  dressing. 
Massage  should  never  be  practised  at  the  beginning  of  a  tubercular 
arthritis,  as  I  have  repeatedly  seen  severe  constitutional  tubercular 
infection  caused  by  quacks  who  have  prescribed  it. 

Injections  of  sterilised  ten-per-cent.  iodoform  oil  or  ten-per-cent. 
iodoform  glycerine  (Bruns)  are  exceedingly  valuable  at  the  commence- 
ment of  the  tubercular  inflammation  of  a  joint,  and  later  on  when 
fistulce  have  developed.  The  manner  of  preparing  and  sterilising  the 
iodoform-oil  emulsion  is  described  on  page  650.  According  to  the  age 
of  the  patient  and  the  size  of  the  affected  joint,  about  every  two  to  four 
weeks  from  two  to  five  to  ten  grammes  of  the  above-mentioned  mix- 
ture are  injected  into  the  joint  and  scattered  through  the  latter  as  far 


§  114.]  THE  CHRONIC  INFLAMMATIONS  OF  JOINTS.  70Y 

as  possible  by  careful  motion  and  gentle  massage.  I  have  seen  very 
remarkable  success  obtained  by  these  iodoform  injections.  Injections 
of  three-per-cent.  carbolic  acid,  chloride  of  zinc  (seven  to  ten  drops  of 
a  ten-per-cent.  solution  at  intervals  of  three  to  seven  days  at  different 
points  in  the  vicinity  of  the  joint  or  of  the  tubercular  focus — Lan- 
nelongue),  arsenic  (acid,  arsenios.  1  to  1,000,  one  to  two  hypodermic 
syringefuls  every  day,  combined  with  the  internal  administration  of 
0.004  to  0.012  grammes  of  arsenic  pro  die),  iodoform  ether,  balsam  of 
Peru,  cinnamic  acid,  etc.,  have  also  been  recommended. 

The  treatment  of  tubercular  arthritis  by  Koch's  tuberculin  has  been 
discussed  on  page  431.  I  have  not  seen  any  satisfactory  results  from 
its  use.  Bier's  treatment  by  constriction  for  the  purpose  of  causing 
passive  congestion  is  described  on  page  431,  and  the  other  methods  for 
treating  tuberculosis  in  §  83. 

It  is  not  always  an  easy  matter  to  decide  whether  operative  meas- 
ures are  necessary,  for  the  simple  reason  that  one  cannot  always  be  sure 
of  the  exact  nature  of  the  pathological  changes  which  are  present.  In 
former  times,  when  the  antiseptic  method  of  treating  wounds  was  first 
introduced,  surgeons  went  too  far  and  performed  resections  of  joints 
too  often,  particularly  in  the  case  of  children  who  suffered  from  tuber- 
cular arthritis.  But  at  present  conservative  treatment  is  employed  as 
much  as  possible,  and  many  joints,  which  would  formerly  have  been 
sacrificed  by  performing  total  resection,  are  now  saved  by  iodoform 
injections,  by  excision  of  the  synovial  membrane,  or  by  scraping  away 
the  diseased  tissue.  Conservatism  should,  however,  not  be  carried  too 
far,  and  some  surgeons  even  to-day  are  in  favour  of  early  and  radical 
operative  measures  in  the  treatment  of  tubercular  arthritis.  The  fre- 
quency of  the  occurrence  of  tubercular  sequestra  shows  that  early 
operative  treatment  is  often  indicated. 

Richet,  Kocher,  and  Yincent  have  recommended  ignipuncture  or 
punctiform  ustion  made  with  the  fistula  tip  of  the  Paquelin  cautery  or 
with  the  galvano-cautery.  I  believe  that  this  procedure  is  suitable 
for  tuberculosis  of  the  synovial  membrane  which  has  not  become  too 
extensive ;  but  after  the  fungous  granulations  have  passed  into  the 
stage  of  suppuration  energetic  operative  measures  are  required.  The 
joint,  after  being  artificially  made  bloodless,  is  opened  and  the  diseased 
parts  then  removed  with  great  care  by  means  of  scissors,  forceps,  and 
the  sharp  spoon ;  but  typical  resection  of  the  articular  ends  of  the 
bones  should  be  performed  only  in  extreme  cases  (see  §  40).  If  the 
tuberculosis  is  purely  of  the  synovial  variety,  and  the  bones  are  healthy, 
we  should,  of  course,  preserve  the  latter  and  content  ourselves  with 
excision  of  the  diseased  membrane  (arthrectomy,  synovectomy).    Early 


708  INJURIES  AND  DISEASES  OF  JOINTS. 

as  well  as  late  resection  of  all  children's  joints,  with  the  exception  of 
the  hip,  should  be  confined  to  as  small  a  number  of  cases  as  possible ; 
energetic  scraping  away  of  the  diseased  bone  with  the  shai-p  spoon, 
but  sparing  the  epiphysis,  or  extirpation  of  the  diseased  synovial 
membrane,  but  leaving  the  bone  untouched  or  removing  some  of 
the  cartilage,  will  almost  always  be  found  sufficient.  By  perform- 
ing early  arthrectomy  with  preservation  of  the  articular  ends  of 
the  bones  in  their  entirety,  or  as  much  of  them  as  possible,  a  perma- 
nent cure  can  often  be  obtained,  and  that,  too,  with  a  movable  joint,  a 
fact  which  is  attested  by  numerous  cases.  Amputation  is  only  per- 
missible in  cases  where  tlie  saving  of  life  comes  into  the  question, 
where  the  destructive  processes  have  become  very  extensive,  or  where 
the  patient  cannot  survive  the  long  period  of  time  required  for  a 
resection  to  heal.  Other  complications  are  treated  according  to  the 
general  principles  which  apply  to  them.  Cold  abscesses  can  with 
impunity  be  freely  opened,  thoroughly  scraped  out  and  drained.  It 
is  very  important  to  recognise  a  tubercular  focus  in  the  neighbour- 
hood of  a  joint  before  it  breaks  through  into  the  latter,  and  to 
remove  it  with  the  sharp  spoon.  After  every  operation  for  tubercular 
arthritis  the  wound  should  be  disinfected  as  carefully  as  possible  to 
prevent  infection  with  bacilli  from  the  wound.  Iodoform  and  iodo- 
form gauze  seem  to  be  the  most  suitable  dressing  materials,  especially 
for  packing  the  joint.  In  most  cases  I  do  not  suture  the  wound,  but 
pack  it  with  sterile  or  iodoform  gauze.  In  the  case  of  the  knee,  I  leave 
the  two  sides  of  the  wound  open,  and  over  the  aseptic  dressing  apply  a 
plaster  splint,  which  is  kept  on  for  four  to  six  weeks.  When  a  tuber- 
cular inflammation  of  a  joint  has  got  well,  some  suitable  splint  appa- 
ratus, such  as  one  of  those  devised  by  Sayre,  Taylor,  or  Thomas,  should 
be  worn,  especially  on  the  lower  extremity,  to  support  the  limb,  which 
will  still  be  weak.  If  any  abnormal  conditions,  such  as  contractures, 
follow  a  tubercular  arthritis,  they  may  have  to  be  treated  by  tenotomy 
of  the  shortened  muscles — or,  rather,  tendons — by  resection,  arthrotomy, 
or  by  a  wedge-shaped  osteotomy,  below  the  trochanter,  for  example^ 
when  the  contracture  involves  the  hip,  unless  they  can  be  stretched 
under  anesthesia  or  gradually  overcoine  by  extension  or  retentive 
appliances  (see  page  220). 

The  treatment  of  tuberculosis  of  the  individual  joints  will  be 
described  in  the  Regional  Surgery. 

y.  The  Syphilitic  Diseases  of  Joints  (see  also  §  84,  Syphilis,  and  page 
652,  Syphilis  of  Bone). — The  syphilitic  diseases  of  joints  have  lately 
been  frequently  and  accurately  described  by  such  men  as  Schiiller, 
Gies,  Falkson,  etc.,  and  their  occurrence  can  be  readily  understood  if 


§114.]  THE  CHRONIC  INFLAMMATIONS   OF  JOINTS.  709 

we  bear  in  mind  that  syphilis  is  a  speciiic  infectious  disease.  The 
joints  become  affected  in  the  course  of  sjphihs,  sometimes  primarily 
and  sometimes  secondarily,  after  syphilitic  disease  in  the  surrounding 
parts,  particularly  the  periosteum,  medulla,  and  the  epiphyses.  The 
syphilitic  inflammations  of  joints  may  be  met  with  during  the  early 
stages  of  the  disease  at  the  time  of  the  febrile  eruption,  or  during  the 
later  periods.  Two  main  classes  of  syphilitic  joint  disease  may  be 
distinguished  :  first,  simple  inflammatory  affections  without  specific 
new-formations ;  and,  second,  those  in  which  there  are  characteristic 
syphilitic  formations,  particularly  gummata.  The  early  forms  are,  in 
the  main,  serous  synovites,  which  occasionally  make  their  appearance 
in  a  manner  analogous  to  acute  polyarticular  rheumatism.  The  inflam- 
mations of  joints  which  occur  in  the  later  stages  of  syphilis  have,  as  a 
rule,  a  pronounced  chronic  character,  and  are  generally  connected  with 
the  formation  of  gummatous  deposits  in  the  periosteum,  the  medulla, 
and  the  synovial  membrane.  After  the  gummatous  nodules  have 
come  to  the  surface  and  ruptured  externally  characteristic  ulcerations 
occasionally  develop.  In  these  late  syphilitic  inflammations  of  joints 
there  will  frequently  be  found  in  the  joint  a  gummatous  or  carious 
destruction  of  the  bones  and  sharply  defined  circumscribed  losses  of 
substance,  or  radiating,  glistening  white  cicatrices  in  the  cartilage, 
together  with  fibrillation  of  the  latter,  while  in  other  instances  a  con- 
nective-tissue growth  in  the  synovial  membrane,  taking  the  form  of 
indurations  or  of  villi,  may  be  more  prominent.  The  pathological 
changes  at  the  first  glance  sometimes  look  like  those  which  occur  in 
arthritis  deformans.  Many  cases  run  a  course  with  a  very  gradual 
increase  in  the  amount  of  swelling,  and  resemble  clinically  tumor 
albus,  but  the  pathological  changes  are  very  different  from  those  of 
tubercular  arthritis.  In  rare  instances  the  gummatous  nodes  occur  in 
the  synovial  membrane  in  a  miliary  form  and  may  be  macroscopically 
mistaken  for  tubercles,  and  then  only  a  microscopic  examination  and 
other  manifestations  of  syphilis  which  may  be  present  will  clear  up 
the  diagnosis.  The  indurated,  villous  connective-tissue  growths,  the 
losses  of  substance  and  the  cicatrices  in  the  cartilage,  and  the  gumma- 
tous, carious  destruction  of  bone  are  characteristic  of  syphilitic  disease 
of  joints.  An  acute,  subacute,  or  chronic  serous  arthritis  may  also 
occur  in  the  later  stages  of  syphilis,  and  primary  suppurative  inflam- 
mation of  a  joint  will  be  encountered  in  rare  instances — for  examjDle, 
when  syphilis  is  complicated  with  gonorrhoea,  etc.  The  congenital 
joint  affections  occurring  in  children,  which  are  usually  chronic,  rarely 
acute  or  subacute,  originate  mainly  in  primary  changes  in  the  epiphyses 
and  epiphyseal  cartilage ;    the  bone  is  enlarged,  and  joint  symptoms 


Ylu 


INJURIES  AND   DISEASES  OF  JOINTS. 


are  either  al)sent  entirely  at  the  outset  or  there  is  a  synovitis  generally 
sei-oiis  in  character.  In  the  later  stages  the  above-described  joint 
affections  may  appear  secondarihj.  There  are,  however,  congenital 
syphilitic  inflammations  of  joints  which  are  suppurative  at  the  start. 

The  tlierapy  of  the  syphilitic  inflammations  of  joints  consists,  in  the 
first  place,  in  a  proper  local  treatment  conducted  according  to  the  rules 
which  have  been  given  for  diseases  of  joints,  and,  secondly,  in  a  gen- 
eral antisyphilitic  treatment,  the  best  being  inunctions,  and  the  next 
best  potassium  iodide,  etc.  (see  §  8-i,  Treatment  of  Syphilis).  The  anti- 
syphilitic  treatment  usually  has  a  very  noticeable  effect,  and  hence  an 
early  diagnosis  is  of  great  importance. 

YI.  Arthritis  Deformans  or  Malum  Senile.— This  affection  is  in  every 
respect  the  opposite  of  tubercular  arthritis.  Suppuration  or  caries  never 
occurs.  The  disease  attacks  individuals  who  are  old  or  past  the  prime  of  life, 
and  almost  always  involves  several  joints.  As  a  rule,  it  causes  deformities 
in  the  joints,  which  very  gradually  become  more  marked,  while  recovery — 
i.  6.,  a  complete  restitutio  ad  integrum — never  occurs,  and  arrest  of  the  pro- 
cess only  rarely. 

The  pathological  changes  which  take  place  in  arthritis  deformans  con- 
sist (1)  in  degenerative  processes  in  the  cartilage  and  bones,  and  (2)  in  hyper- 
plasia of  the  bones,  cartilage,  and  soft  parts.  A  fibrillation  occurs  in  the 
more  superficial  layers  of  the  ground  substance  of  the  hyaline  cartilage, 
while  a  localised  cracking  and  softening  are  produced  in  the  deeper  layers 
by  the  vascular  medullary  spaces  of  the  underlying  bone  pushing  their  way 

into  the  cartilage.  At  the  same  time,  par- 
ticularly at  the  free  borders,  a  growth  of 
cartilage  occui-s  taking  the  form  of  knob- 
like tuberosities,  which  subsequent!}',  for 
the  most  part,  ossify  (Figs.  444:,  44()).  In 
consequence  of  the  degenerative  fibrilla- 
tion and  softening  of  the  cartilage  (arthritis 
chronica  ulcerosa  sicca)  the  latter  may  com- 
pletely disappear,  exposing  the  uncovered 
bone,  which  then,  by  the  friction  produced 
in  the  movements  of  the  joint,  develops  a 
smooth,  polished  surface  (Fig.  446,  a). 

The   degenerative  changes  which  take 
Ijlace  in  the  bone  consist  in  a  lacunar  ab- 
sorption and  inflammatory  atrophy  of  the 
bone  tissue,  for  the  most  part  subchondral. 
The  atrophy  of  bone  is  occasionally  very 
considerable,   and  may  lead  to  the  disap- 
pearance of  the  head  or  entire  neck  of  the 
femur  (Figs.  444,  445).     Just  as  in  the  case 
of  cartilage,  there  will  be  encountered  in  addition  to  the  atrophy  a  new  for- 
mation of  bone  which  is  sometimes  very  marked  ("Figs.  445,  446).     In  some 
cases  the  atrophy  of  the  bone  predominates  (Fig.  444),  in  others  the  new  for- 


FiG.  444. — Coxitis  deformans  :  head  of 
the  femur  below  the  tip  of  the  great 
trochanter ;  neck  of  the  femur  no 
longer  present  (Path,  collection  in 
Zurich — Volkmannj. 


§  114.] 


THE   CHRONIC   INFLAMMATIONS  OP  JOINTS. 


Yll 


Biation  of  bone  (Fig.  446).  These  degenerative  and  hyperplastic  changes  in 
the  cartilage  and  bone  are  very  characteristic  of  arthritis  deformans.  The 
capsule  and  ligaments  of  the  joints  also  become  thickened  and  afterwards 
contracted,  and  the  synovial  villi  become  the  seat  of  an  active  process  of 
proliferation.  Loose  -  joint  bodies 
(see  §  115)  are  very  frequently  found 
in  the  joint,  but  adhesions  between 
the  articular  surfaces  of  the  bones  or 
obliteration  of  the  joint  by  newly- 
formed  connective  tissue  almost 
never  occur. 

The  joints  gradually  become  so 
deformed  by  these  changes  in  the 
articular  ends  of  the  bones  and  by 
the  thickening  and  shrinking  of  the 
capsule,  which  is  sometimes  the  seat 
of  a  new  formation  of  bone,  that  mo- 
tion becomes  more  or  less  limited 
or  entirely  lost.  If  the  atrophic 
changes  in  the  bones  predominate 
the  joint  may  become  abnormally 
mobile  or  even  loose  and  flail-like, 
with  a  tendency  towards  subluxa- 
tion or  complete  dislocation  (luxa- 
tions of  deformity,  as  they  are 
called).  These  dislocations  cannot, 
as  a  rule,  be  kept  permanently  re- 
duced owing  to  the  deformities  of 
the  head  of  the  bone  and  the  socket, 

and  in  the  case  of  dislocations  of  the  head  of  the  femur  a  new  acetabulum 
may  be  formed  on  the  ilium  (Fig.  447). 

Arthritis  deformans  is  most  commonly  observed  in  tlie  hip,  knee, 
elbow,  and  shoulder,  and  less  often  in  joints  of  the  fingers  and  verte- 
brae. In  the  vertebrae  the  atrophy  of  bone  may  cause  the  development 
of  spinal  curvatures,  especially  kyphosis,  while  the  new  formation  of 
bone  may  give  rise  to  osseous  union  between  the  different  vertebrae. 
Arthritis  deformans  is  either  monarticular  or  polyarticular.  If  monar- 
ticular, it  is  usually  located  in  a  large  joint,  while  the  polyarticular 
form  more  commonly  occurs  in  the  small  joints,  such  as  those  of  the 
fingers  or  toes,  etc. 

We  still  know  little  about  the  etiology  of  this  disease,  though  its 
anatomical  peculiarities  are  so  characteristic.  It  may  begin  spontane- 
ously, or  follow  the  reception  of  some  traumatism,  such  as  a  fracture 
which  involves  the  joint,  or  come  on  after  some  such  infectious  inflam- 
mation as  a  gonorrhoeal  arthritis,  or  after  acute  polyarticular  rheu- 
matism.    The  patient's  occupation  or  position  in  life  plays  no  part  in. 


Fig.  445. — Arthritis  deformans  of  the  hip-joint : 
the  greatly  enlarged  head  of  the  femur  lies 
very  near  the  trochanter  owing  to  the  dis- 
appearance of  tlie  neck  (Path.  Institute  at 
Leipsicj. 


"12 


INJURIES  AND   DISEASES  OF  JOINTS. 


the  causation  of  arthritis  deformans,  but  his  age  probably  does.  I  look 
upon  this  affection  as  essentially  a  senile  disorder  which,  as  a  rule,  can 
be  traced  to  some  exciting  cause,  such  as  a  traumatism  or  an  infection 
— it  is  rarely  spontaneous — and  gives  rise  to  characteristic  atrophy  and 
to  hyperplasia  of  the  cartilage  and  bone,  and  to  thickening  and  con- 
traction of  the  capsule. 

The  clinical  course  oi  both  the  monarticular  and  polyarticular  form 
of  arthritis  deformans  is  exceedingly  chronic,  and  it  is  not  an  uncom- 
mon thing  for  the  disease  to  last  twenty  to  thirty  years.  The  initial 
symptoms  are  those  of  a  chronic  arthritis  running  a  course  without 
fever,  and  consist  in  stiffness  of  the  joint,  particularly  in  the  morning 

hours,  in  slight  pains, 
and  in  the  occuri-ence 
of  crepitating  or  creak- 
ing sounds.  Later  on 
the  deformities  of  the 
articular  ends  of  the 
bones  or  of  the  entire 
joint  become  promi- 
nent. The  movements 
of  which  the  joints  are 
capable  become  more 
and  more  restricted,  or 
the  opj^osite  condition 
may  exist,  the  joints  be- 
coming loose  and  flail- 
like. Occasionally  acute 
inflammatory  symp- 
toms make  their  ap- 
pearance, consisting  of 
fever,  increased  tender- 
ness and  inflammatory 
swelling  of  the  joint,, 
and  an  acute  effusion 
of  serum.  The  pain 
may  be  excessive.  Recovery  is  extremely  rare,  the  disease  ordinarily 
growing  worse  very  gradually  until  it  is  terminated  by  death  from 
some  intercurrent  affection. 

Diagnosis. — The  very  chronic  course  of  the  disease,  the  absence  of 
suppuration  and  caries,  the  characteristic  deformity  of  the  joints,  the 
advanced  age  of  the  patient,  and  the  history  of  some  predisposing 
cause,  are  important  factors  in  the  diagnosis  of  arthritis  deformans. 


h^^ 


condyl.  ext. 


condyl.  int. 


Fig.  446. — Arthritis  deformans  of  the  right  knee-joint :  a,  pol- 
ished and  smooth  articular  surface  ;"6,  growth  of  bone  and 
cartilage ;  c,  fibrillation  of  the  cartilage ;  unequal  length 
of  the  femoral  condyles,  giving  rise  to  pronounced  genu 
valgum ;  the  transverse  diameter  of  the  internal  condyle 
and  the  longitudinal  diameter  of  the  external  condyle 
are  shortened  (Path.  Institute  at  Leipsic). 


§  114.] 


THE   CHRONIC  INFLAMMATIONS  OF  JOINTS. 


713 


Fig.  447. — Formation  of  a  new  acetabulum 
(^•1)  on  the  OS  ilium  after  a  dislocation 
from  arthritis  deformans  in  a  woman 
seventy  years  old ;  B,  remains  of  the 
original  acetabulum  (Gutsch). 


The  Treatment  of  Arthritis  Deformans. — The  sooner  arthritis  de- 
formans is  subjected  to  systematic  treatment  by  massage  and  active 
and  passive  movements  of  the  joint, 
the  greater  is  the  possibihtj,  particu- 
larly in  the  case  of  the  monarticular 
form,  of  arresting  the  further  devel- 
opment of  the  disease.  In  addition, 
to  massage  and  methodical  exercise  of 
the  joint,  baths  in  which  the  entire 
body  is  immersed  in  lukewarm  water, 
or  sand  baths,  mud  baths,  or  steam 
baths,  combined  with  cold  douches — 
in  short,  hydrotherapeutic  measures 
— are  especially  to  be  recommended. 
The  use  of  hot  springs,  such  as  Gas- 
tein,  Wildbad,  Wiesbaden,  Teplitz, 
Ragatz,  etc.,  and  a  residence  in  south- 
ern climates,  are  also  exceedingly 
serviceable.  Marked  disturbances  of 
function,  especially  in  the  upper  ex- 
tremity, can  be  improved  by  performing  resection.  The  latter  has  been 
repeatedly  practised  for  severe  pain,  the  results  in  some  cases  being 
excellent  and  in  others  entirely  negative.  The  ojDerative  treatment  of 
arthritis  deformans  (synovectomy  with  or  without  resection  of  the 
articular  surfaces),  should,  in  my  opinion,  be  tried  more  often  than  it 
is,  considering  the  hopelessness  of  other  methods  of  treatment.  In 
the  very  rarest  cases  amputation  is  indicated  on  account  of  marked 
functional  disturbances.  The  other  complications,  such  as  the  acute 
exacerbations,  dislocations,  or  loose  joints,  which  sometimes  occur,  are 
treated  according  to  the  general  rules  which  apply  to  these  conditions. 
The  internal  administration  of  drugs,  such  as  iodide  of  potassium, 
aconite,  quinine,  iron,  etc.,  is  of  little  use,  but  a  strengthening  mode  of 
life  with  nourishing  food,  fresh  air,  etc.,  is  very  important. 

The  Diseases  of  Joints  which  occur  in  Bleeders  {Haemophilia ;  see  page 
63). — Individuals  who  suffer  from  hjemophilia  are  sometimes  affected  by- 
various  kinds  of  joint  diseases,  which  generally  take  on  a  serious  character 
owing  to  the  presence  of  the  constitutional  dyscrasia.  Leaving  out  of  con- 
sideration the  different  forms  of  inflammation  of  joints  which  occasionally 
occur  in  bleeders  as  well  as  in  other  people,  there  is  left  a  certain  definite 
group  of  joint  diseases  which  are  clinically  and  pathologically  peculiar  to 
haemophilia,  and  which  are  to  be  regarded,  so  to  speak,  as  a  symptom  of  this 
disease.  Konig  has  recently  described  "  bleeder  joints  "  very  much  at  length, 
and  I  can  fully  confirm  his  statements.    These  typical  joint  diseases  which  are 


714  INJURIES  AND  DISEASES  OF  JOINTS. 

met  witli  ill  haemophilia  are  characterised  by  the  presence  in  tlie  joint  of  an 
effusion  of  blood,  which  may  persist  in  an  unaltered  state  for  weeks  and  then 
gradually  grow  smaller,  and,  if  the  conditions  are  favourable  and  compres- 
sion is  employed,  may  eventually  entirely  disappear.  But  in  other  instances, 
particularly  if  the  disease  is  not  properlj-  treated,  the  effusion  of  blood  is 
added  to  by  fresh  luemorrhages,  the  joint  becomes  gradually  more  and  more 
damaged,  the  articular  cartilages  undergo  erosion  and  fibrillation,  and  the 
joint  grows  constantly  stiffer,  finally  becoming  obliterated.  If  the  unfavour- 
able conditions  continue,  contractures  and  deformities  of  the  joints  develop. 
It  is  a  vei'y  easy  matter  to  mistake  a  bleeder  joint,  particularly  during  the 
early  stages,  for  hydrops  tuberculosus,  and  later  for  fully  developed  tubercu- 
losis (tumor  albus).  Ivonig  lost  two  patients  fx'om  haemorrhage  because  he 
had  thought  the  articular  disease  was  tubercular  and  consequently  under- 
took extensive  operations.  In  making  the  diagnosis  of  a  bleeder  joint  the 
personal  history  of  the  patient  is  of  the  utmost  importance,  for  the  reason 
that  the  patients  or  their  parents  are  generally  aware  of  their  bleeder  disease. 
It  should  be  noted  that  it  almost  always  occurs  in  young  subjects,  the  large 
effusion  of  blood  usually  develops  suddenly  from  some  slight  traumatism, 
pain  is  generally  absent,  and  several  joints  are  commonly  affected,  some 
being  in  the  early  and  others  in  the  advanced  stages. 

The  treatment  of  recent  cases  consists  in  placing  the  limb  in  an  elevated 
position,  in  immobilisation  and  compression  of  the  joint,  and  subsequently 
in  gentle  massage  and  passive  motion.  In  some  instances  the  joint  should 
be  punctured  for  the  purpo.se  of  removing  the  effused  blood.  Massage  should 
be  used  cautiously.  Cerebral  htemorrhage  due  to  traumatism  or  pathologi- 
cal processes  are  sometimes  accompanied  b}^  effusions  of  blood  in  the  large 
joints,  which  are  probably  caused  by  trophic  changes  in  the  walls  of  the  ves- 
sels, and  appear  after  an  injury,  for  example. 

§  115.  Joint  Bodies  or  Joint  Mice  {Mures  Articulares). — By  joint 
bodies  or  the  so-called  joint  mice  (mures  articulares)  we  mean  bodies 
varying  in  structure  which  are  formed  within  joints  and  are  either  free 
or  attached  bj  pedicles.  Joint  bodies  anatomically  consist  of  cartilage 
or  of  bone,  or  of  bone  with  a  cartilaginous  covering,  of  fibrous  connect- 
ive tissue,  of  fatty  tissue,  or  of  masses  of  fibrin. 

We  are  able  to  distinguish  etiologically  three  principal  kinds  of 
joint  bodies  :  (1)  Concretions  made  up  of  fibrin,  (2)  joint  bodies  result- 
ing from  the  breaking  off  of  cartilaginous  or  bony  portions  of  the  articu- 
lar ends  of  the  bones  or  intra-articular  ligaments  by  some  traumatism, 
and  (3)  growths  of  connective  tissue,  cartilage,  or  bone  which  originally 
are  pedunculated,  but  later,  as  a  result  of  atrophy  or  sudden  rupture  of 
the  pedicle,  become  free  joint  bodies.  Out  of  one  hundred  and  forty- 
three  cases  collected  by  Schiiller,  eighty-three  were  caused  by  trau- 
matism (seventy-eight  of  the  knee-joint),  thirty-nine  by  pathological 
processes,  and  in  nineteen  the  mode  of  production  was  unknown. 

The  fibrin  concretions — i.  e.,  the  fibrin  precipitated  from  the  .syno- 
via in  cases  of  chronic  hydarthros,  for  example,  with  or  without  tuber- 


§115.]  JOINT  BODIES  OR  JOINT   MICE.  7I5 

culosis — take  the  form  of  round,  smooth,  or  irregularly  shaped  concre- 
ments,  usually  about  the  size  of  a  melon  seed  or  grain  of  rice,  which 
often  occur  in  great  numbers.  These  concrements,  from  their  simi- 
larity to  grains  of  rice,  are  also  called  rice  bodies  (corpora  oryzoidea). 
According  to  Konig,  Landon,  and  others,  all  rice  bodies  that  are  found 
in  tubercular  joints,  tendon  sheaths,  and  bursse  are  derivatives  of  the 
fibrin  formed  in  the  synovial  fluid  and  on  the  surface  of  the  synovial 
membrane.  Schuchardt  and  Goldmann  maintain  that  the  rice  bodies 
are  not  "  fibrinous  "  products  of  coagulation  formed  from  the  thickened 
contents  of  a  joint  or  tendon  sheath,  but  are  portions  of  the  synovial 
membrane  or  tendon  sheath  which  have  undergone  coagulation  necro- 
sis (Weigert)  or  fibrinoid  degeneration  (I^eumann).  In  my  opinion, 
both  methods  of  development  of  rice  bodies  occur,  but  the  primary 
degeneration  of  the  synovial  membrane  is  much  the  more  common, 
particularly  in  tuberculosis  of  the  joint.  Rice  bodies  are  especially 
common  in  tubercular  arthritis,  and,  in  fact,  the  occurrence  of  these 
bodies  in  a  joint  makes  the  existence  of  tubercular  disease  probable. 
Such  cases  sometimes  run  a  very  favourable  course.  (See  also  pages 
579  and  581,  Formation  of  Rice  Bodies  in  the  Tendon  Sheaths  and 
Bursse).  Occasionally  the  concrements  attain  a  considerable  size — that 
of  a  hen's  egg,  for  example,  or  larger.  Small  foreign  bodies,  such  as 
needle  points,  broken-oif  synovial  villi,  a  blood-clot,  etc.,  have  been 
found  in  the  interior  of  the  concretions,  just  as  in  vesical  calculi. 

In  the  second  category  of  cases  the  free  joint  bodies  are  formed 
from  bony  or  cartilaginous  portions  of  the  articular  ends  of  the  bones 
or  intra-articular  ligaments  which  are  torn  from  their  attachments  by 
some  traumatism,  such  as  a  blow,  a  fall,  or  some  other  violence.  Occa- 
sionally the  detachment  is  not  complete,  and  then  at  some  later  period 
there  takes  place  a  gradual  or  sudden  separation  of  the  partially  de- 
tached piece  of  bone  or  cartilage.  Kragelund  was  able  only  by  using  a 
great  amount  of  force  to  partially  or  completely  break  oif  from  the 
femur — generally  the  internal  condyle — but  not  from  the  tibia,  por- 
tions of  bone  which  presented  a  close  similarity  to  mures  articulares, 
and  Poncet  saw  small  fragments  of  bone  torn  from  the  points  where 
the  ligaments  were  attached.  Gies,  Poncet,  Barth,  and  others  have 
opened  the  joints  of  animals,  chiseled  off  portions  of  the  articular  sur- 
face, and  then  closed  the  wound  in  the  joint,  which  healed  by  primary 
union.  The  behaviour  of  these  free  portions  of  cartilage  is  as  follows 
(Barth) :  "  Free  pieces  consisting  of  bone  and  cartilage  usually  become 
adherent  to  the  capsule  and  articular  surfaces,  and  are  inclosed  by  vascu- 
lar connective  tissue  ;  the  bony  portion  dies,  while  the  cartilage  retains 
its  vitality,  grows,  and  gives  rise  to  a  new  formation  of  bone,  using  the 


716  INJURIES  AND  DISEASES  OF  JOINTS. 

lime  salts  of  the  dead  bone.  In  consequence  of  vigorous  growth  of 
the  cartilage,  free  bodies  with  an  external  layer  of  cartijage  and  a  cen- 
tral bone  nucleus  may  result,  and  their  union  with  the  capsule  of  the 
joint  becomes  severed.  Joint  bodies  that  are  not  united  to  the  capsule 
are  sometimes  absorbed,  but  this  is  a  rare  occurrence  in  man,  because 
the  bodies  of  traumatic  origin  tend  to  calcilication. 

Furthermore,  without  the  reception  of  any  traumatism,  larger  or 
small  pieces  may  become  separated  from  the  articular  ends  of  the  bones 
as  a  result  of  some  process  which  is  not  as  yet  understood  ;  these  pieces 
are  then  covered  on  their  bony  surfaces  with  dense  connective  tissue 
which  contains  cartilage  cells,  and  the  loss  of  substance  in  the  bone 
from  which  they  came  is  repaired  in  a  similar  manner.  Konig  has 
given  the  name  of  osteochondritis  dissecans  to  this  genetically  obscui*e 
and  circumscribed  disease  of  the  articular  ends  of  the  bones. 

The  third  way  in  which  joint  bodies  may  originate — i.  e.,  in  the  form 
of  steadily  enlarging  growths  of  tissue  attached  by  a  pedicle  to  some 
part  of  the  articulation,  such  as  the  villi,  the  sjnaovial  membrane,  or 
the  articular  cartilages — is  met  with  especially  in  chronic  joint  diseases, 
such  as  arthritis  deformans  or  chronic  hydarthros,  or  after  fractures 
which  involve  the  joint.  The  growths  are  made  up,  according  to  the 
point  from  which  they  spring,  of  connective  tissue,  cartilage,  or  bone, 
or  bone  with  a  cartilaginous  covering,  and  then  by  gradual  atrophy  or 
by  sudden  rupture  of  the  pedicle  these  growths  become  free  joint 
bodies.  In  this  category  belong  the  free  joint  bodies  formed  by 
growth  of  the  synovial  villi  or  by  fibrillation  of  the  cartilage,  as  well  as 
those  which  result  from  the  detachment  of  tumours  of  cartilage  or  bone 
(enchondroma,  osteoma),  or  of  the  cartilaginous  or  bony  plates  in  the 
synovial  membrane  which  may  develop  in  the  course  of  hydarthros  and 
arthritis  deformans.  As  a  result  of  the  fibrillation  of  the  articular 
cartilage  occurring  in  a  chronic  arthritis,  there  is  often  a  very  excessive 
formation  of  cartilaginous  villi  in  which  a  vigorous  circumscribed 
growth  of  cartilage  cells  sometimes  takes  place.  If  these  formations 
become  loose,  hyaline  rice  bodies  analogous  to  the  above-mentioned 
fibrinous  rice  bodies  develop,  having  exactly  the  same  form  as  the  latter, 
and  likewise  existing  in  very  great  numbers.  The  condition  in  which 
there  is  an  excessive  growth  of  fat  in  the  villi  is  called  lipoma  arbor es- 
cens,  and  may  give  rise  to  the  formation  of  free  joint  bodies  which  are 
soft  and  made  up  of  fat.  The  cartilaginous  and  bony  joint  bodies 
vary  greatly  in  size,  some  being  not  larger  than  a  bean  or  almond, 
while  others  are  as  large  as  the  patella.  Billroth  states  that  a  joint 
body  has  been  preserved  in  the  museum  at  Yienna  as  large  as  the  os 
calcis,  which  was  found  attached  by  a  pedicle  to  the  capsule  of  the 


§115.]  JOINT  BODIES  OR  JOINT  MICE.  YIT 

joint.  An  important  question  is  whether  a  perfectly  free  joint  body 
can  continue  to  grow.  Yirchow  and  others  consider  this  possible 
through  the  taking  up  of  fluid  from  the  synovia  and  by  proliferation 
of  cartilage  and  marrow  cells  in  the  case  of  cartilaginous  and  bony 
joint  bodies.  In  some  cases,  however,  retrograde  changes  may  pre- 
dominate, and  small  bodies  can  be  absorbed  completely. 

Symptomatology  and  Diagnosis  of  Free  Joint  Bodies. — As  we  stated 
before,  joint  bodies  are  found  in  joints  which  are  either  otherwise  per- 
fectly healthy  or  are  the  seat  of  chronic  inflammation,  particularly 
chronic  hydarthros,  arthritis  deformans,  and  joint  fractures  that  have 
not  healed,  by  bony  union.  Out  of  forty -five  cases  of  loose  bodies 
collected  by  Barth,  severe  symptoms  of  joint  disease  were  present  in 
thirty -nine.  The  disturbances  either  begin  immediately  after  an  injury 
or  they  develop  very  gradually  in  the  course  of  years.  The  knee-joint 
is  the  most  common  location  in  which  they  are  encountered,  while  of 
the  other  joints  the  elbow  comes  next.  The  symptoms  caused  by  free 
joint  bodies  are,  first  of  all,  a  sudden,  severe,  darting  pain,  experienced 
during  some  particular  movement  of  the  joint,  often  causing  the  patient 
to  appear  as  though  paralysed  and  to  fall  to  the  ground  in  a  faint. 
These  pains,  which  reappear  with  more  or  less  frequency,  are  par- 
ticularly hkely  to  occur  when  a  moderate-sized,  freely  movable  joint 
body  becomes  caught  in  a  synovial  pouch  or  between  the  articular  ends 
of  the  bones.  The  attacks  of  pain  are  usually  followed  by  inflam- 
matory manifestations  in  the  joint  of  greater  or  less  severity,  which 
take  the  form  of  an  acute  serous  synovitis. 

Diagnosis. — These  characteristic,  paroxysmal  pains  are  of  the  great- 
est importance  for  making  the  diagnosis  of  free  joint  bodies.  In  some 
instances  the  latter  can  be  felt.  ^Nevertheless,  one  can  be  deceived 
even  in  this,  and  I  once  mistook  a  commencing  circumscribed  tubercu- 
losis of  the  capsule  of  the  knee-joint  for  a  free  joint  body.  After 
opening  the  joint  and  extirpating  the  diseased  portion  of  the  capsule, 
recovery  took  place,  with  perfect  motion  in  the  joint.  The  most  difii- 
cult  cases  to  recognise  are  those  in  which  the  joint  bodies  exist  in  an 
articulation  which  has  undergone  changes  due  to  arthritis  deformans. 

Treatment.^-The  best  treatment  for  free  joint  bodies  consists  in 
their  operative  removal  by  aseptic  arthrotomy.  The  body  having  been 
located  by  palpation,  an  incision  is  made  directly  down  upon  it,  where- 
upon it  is  pressed  through  the  opening  thus  made  and  the  borders  of 
the  wound  are  immediately  closed  by  sutures.  The  joint  is  then  im- 
mobilised as  completely  as  possible  with  an  antiseptic  protective  dress- 
ing, over  which  splints  are  placed.  If  the  patient  is  afraid  of  the 
knife,  or  if  the  condition  does  not  cause  him  much  trouble,  we  recom- 


Y18  INJURIES  AND   DISEASES  OF  JOINTS. 

mend  the  wearing  of  an  elastic  cap  around  the  joint,  to  afford  the  latter 
a  certain  amount  of  support  and  prevent  too  free  motion.  In  those 
cases  where  the  symptoms  indicate  beyond  a  doubt  the  presence  of  a 
joint  body,  but  where,  as  in  the  elbow,  it  cannot  be  reached  hj  an 
incision  made  directly  down  upon  it,  in  case  the  patient's  discomfort  is 
great  enough,  the  joint  should  be  laid  freely  open  with  the  strictest 
aseptic  precautions,  and,  if  necessary,  a  partial  (temporary)  resection 
undertaken  to  render  it  possible  to  remove  the  joint  body. 

Exostosis  Bursata  with  Joint  Bodies. — Bergmaun  operated  upon  an  exos- 
tosis on  the  outer  aspect  of  the  lower  end  of  the  femur,  just  above  the  knee, 
which  was  surrounded  by  a  capsule  containing  upwai'ds  of  five  hundred  rice 
bodies  made  up  of  hyaline  cartilage.  The  exostosis  probably  originated 
intra-articularly  as  an  ecchondrosis  of  the  articular  cartilage,  and  derived  a 
true  synovial  sac  by  pushing  before  it  the  capsule  of  the  joint,  the  tlivertic- 
ulum  thus  formed  becoming  afterwards  completely  shut  off  from  the  joint. 
In  other  instances  the  exostosis  has  been  found  still  in  the  joint,  as  in  two 
cases  of  mine,  where  it  was  attached  to  the  portion  of  the  semilunar  cartilage 
which  adjoins  the  capsule.  In  these  cases  there  were  in  addition  two  bodies 
lying  free  in  the  joint  (see  Exostoses,  §  128). 

§  116.  Neuroses  of  Joints  (Neuralgias  of  Joints;  Nervous,  Hysterical 
Diseases  of  Joints). — The  nervous  or  hysterical  affections  of  joints,  the 
neuroses  or  neuralgias  of  joints,  were  first  described  by  the  celebrated 
English  surgeon  Brodie,  and  his  statements  have  been  confirmed  hy 
such  German  surgeons  as  Stromeyer,  Esmarch,  and  Erb ;  while  quite 
recently  NcAvton  M.  Shaffer  has  written  an  exhaustive  treatise  on  the 
subject.  IS^o  pathological  changes  can  be  made  out  in  joints  whicli  are 
the  seat  of  neuralgia.  The  knee  and  hip  are  the  ones  most  commonly 
affected,  and  usually  one  joint  at  a  time,  rarely  two  or  more.  Females 
with  an  over-excitable  nervous  system,  or  who  are  markedly  hysterical, 
especially  young  girls  of  the  better  classes  of  society,  are  particularly 
apt  to  suffer  from  these  troubles,  and  lience  the  term  hysterical  joint. 
But  the  affection  is  occasionally  met  with  even  in  perfectly  healthy 
men  and  women.  Among  the  exciting  causes  may  he  mentioned  trau- 
matisms, .such  as  bruises  and  sprains  of  the  joints,  irritation  of  or 
pressure  upon  the  nerves  in  the  neighbourhood,  excessive  emotional 
disturbances,  and  taking  cold.  Joint  neuralgias  also  occur  i-eflexly 
from  diseases  of  the  abdominal  viscera,  especially  the  female  sexual 
organs,  and  from  diseases  of  the  central  nervous  system,  such  as  tabes. 

Symptoms  and  Course  of  Joint  Neuroses. — The  chief  symptom  of  a 
joint  neuralgia  or  neurosis  is  the  pronounced  pain  and  tenderness  in 
the  joint,  while  objectively  nothing  abnormal  can  be  made  out.  The 
pain  is  felt  especially  when  pressure  is  made  at  some  particular  point, 
or  when  the  joint  is  moved.     In  addition  to  these  tender  points,  there 


§116.]  NEUROSES   OF   JOINTS.  719 

is  generally  a  pronounced  diffuse  hypersestliesia  of  the  skin  over  the 
joint ;  but  in  rare  instances  there  may  be  anaesthesia.  Moreover,  the 
function  of  the  joint  in  question  is  disturbed — i.  e.,  the  patient  avoids 
moving  the  joint  because  of  the  pain,  and  keeps  it  rigid.  There  are 
also  observed  a  state  of  muscular  spasm,  with  secondary  distortions 
of  the  joints  (contractures) ;  vasomotor  disturbances  (urticaria-like 
wheals,  alternate  flushing  and  blanching,  etc.) ;  tremor ;  a  marked 
feeling  of  weakness ;  atrophy  of  the  extremity  which  is  involved,  and 
now  and  then  paralyses.  The  stiffness  and  contractures  of  the  joints, 
which  may  take  the  form  of  nervous  club-foot  or  stiffness  of  the  hip, 
will  immediately  disappear  under  chloroform  anaesthesia,  and  while 
the  patient  is  in  this  state  the  joint  will  be  freely  movable.  The  verte- 
bral column,  especially  the  spinous  processes,  are  also  sometimes  tender 
on  pressure.  The  course  of  the  nervous  joint  affections  is  usually 
rather  tedious  and  very  variable.  If  the  nervous  system  is  otherwise 
normal,  recovery  generally  takes  place  after  the  lapse  of  a  longer  or 
shorter  time,  though  it  may  occur  suddenly  after  some  emotional 
excitement  or  after  some  energetic  movements  have  been  made  with 
the  joint.  In  cases  of  pronounced  hysteria,  or  diseases  of  the  nervous 
system,  the  patients  are  occasionally  doomed  to  be  confined  to  bed  for 
years,  and  in  such  instances  the  affection  is  often  incurable. 

In  making  the  diagnosis  of  a  hysterical  joint,  we  should  note  particu- 
larly that  certain  symptoms  which  indicate  inflammation  of  the  joint  are 
absent,  and  that  the  contractures,  the  stitfnes^,  etc.,  disappear  completely 
under  chloroform  ansesthesia.  The  above-mentioned  manifestations  of  the 
disease  are  so  characteristic  that  they  are  generally  sufficient  to  establish  the 
diagnosis.  Old  sprains  with  slight  intra-articular  adhesions  have  sometimes 
been  mistaken  for  joint  neuralgias  ;  but  cases  of  this  kind  can  be  cured  in  a 
very  short  time  by  massage  combined  with  forced  movements  of  the  joint. 

The  prognosis  is  favourable  in  the  case  of  individuals  who  are  otherwise 
healthy ;  but  if  they  are  excessively  neurotic  and  hysterical,  it  is  uncertain, 
and  is  the  more  unfavourable  the  more  serious  the  nervous  complications. 

Treatment. — The  treatment  of  nervous  joint  affections  is  directed 
first  of  all  towards  the  cause.  If  there  is  pronounced  neurasthenia, 
hysteria,  or  other  nervous  anomalies,  or  disease  of  certain  organs  (of 
the  sexual  organs,  constipation,  etc.),  these  conditions  must  receive 
careful  attention.  In  every  case  a  general  tonic  treatment  for  the 
nervous  system  by  cold-water  cures,  sea-bathing,  a  sojourn  in  the 
mountains,  and  removal  of  the  patient  from  his  business  and  family, 
are  very  much  to  be  recommended.  Treatment  of  a  psychical  nature  is 
also  very  valuable ;  while  unexpected  joy  or  sorrow  has  often  caused 
hysterical  joint  neuroses  to  disappear  suddenly  and  permanently.  The 
local  treatment  of  the  diseased  joint  comprises  massage  and  method- 


Y20  INJURIES  AND   DISEASES  OF  JOINTS. 

ical  exercise,  nibbing  with  cold  water,  and  electricity  (the  strong 
faradic  or  galv^anic  current  passed  transversely  through  the  joint). 
Morphine  or  atropine  is  occasionally  given  in  the  form  of  hypodermic 
injections  if  the  patient  is  otherwise  healthy  and  robust.  Quinine  and 
arsenic,  given  internally,  are  also  of  use.  For  the  contractures  and 
the  weakness  of  the  muscles  and  joints  we  employ  suitable  braces  or 
splints  which  will  enable  the  patient  to  move  his  limbs. 

Other  Joint  and  Bone  Neuralgias. — The  neui'algias  sometimes  occurring 
in  joints  and  bones  wliich  have  previously  been  the  seat  of  a  disease  like 
tubercular  arthritis,  or  which  make  their  appearance  in  the  course  of  syphi- 
lis, or  after  recovery  from  caries  and  necrosis,  or  in  general  occur  in  old  bone 
cicatrices,  are  of  a  totally  different  natui'e.  Pain  of  this  description  is  very 
apt  to  occur  in  syphilis,  or  in  ossifying  osteomyelitis  and  periostitis,  or  in 
sclerosis  of  bone.  The  treatment  of  these  joint  and  bone  neuralgias  depends 
upon  the  cause.  Warm  baths  and  the  bathing  cures  given  at  Teplitz,  Wies- 
baden, and  Gastein  are  genei'ally  very  useful.  The  pain  occui'ring  in  bones 
and  joints  which  have  been  at  one  time  diseased  may  sometimes  become  so 
severe  that  amputation  or  disarticulation  is  performed  at  the  patient's  own 
request.  Close  examination  of  the  bone  in  such  cases  reveals  nothing  which 
can  account  for  the  great  suffering,  but  we  do  find  that  individuals  thus 
affected  are  usually  neurotic  (Poncet,  Auday). 

Quite  often,  however,  these  neuralgias  are  due  to  circumscribed,  inflam- 
matory foci  concealed  in  the  bone  or  joint,  and  if  this  is  the  case  the  disease 
should  receive  its  appropriate  treatment.  Abnormal  adhesions  in  a  joint, 
such  as  may  occur,  for  example,  in  old  dislocations  which  have  been  improp- 
erly treated,  may  give  rise  to  violent  pains,  which  can  be  quickly  stopped  by 
massage  and  exercise.  In  general,  neuralgias  of  joints  and  bones  follow- 
ing a  pre-existing  disease  are  most  commonly  the  result  of  syphilis  or  some 
nervous  disease ;  and  these  must  be  the  first  things  to  be  considered  in  the 
treatment. 

Sometimes  violent  pain  also  occurs  in  bones  which  are  otherwise  appar- 
ently healthy  and  have  not  previously  been  diseased,  coming  on  especially 
after  taking  cold,  and  in  neui'otic  individuals.  Warm  baths  and  the  use  of 
the  above-mentioned  hot  springs,  as  well  as  an  antineuvotic  treatment,  should 
be  employed. 

§  117.  Neuropathic  Diseases  of  Bones  and  Joints. — Peculiar  neuro- 
pathic affections  of  the  bones  and  joints,  of  great  clinical  intei'est,  oc- 
cur in  the  course  of  diseases  of  the  nerves  and  spinal  cord,  especially 
tabes.  Charcot  was  the  first  to  describe  accurately  the  arthropathies 
which  make  their  appearance  during  the  course  of  the  grey  degenera- 
tion of  the  posterior  columns  of  the  coi'd ;  and  while  Charcot,  Erb, 
Buzzard,  and  other  neurologists  ascri1)e  the  arthropathia  tabidorum  to 
direct  nervous  influences — in  other  words,  to  trophoneurotic  disturb- 
ances— Yolkmann,  Leyden,  and  Yirchow  maintain  that  the  tabes 
merely  brings  about  unfavourable  conditions,  in  consequence  of  which 


§117.]  NEUROPATHIC  DISEASES   OF   BONES  AND  JOINTS.  721 

certain  diseases  of  the  joints  occur  more  easily  and  frequently  than 
they  do  in  a  state  of  health,  and  run  an  unusual  and  malignant  course. 
The  main  predisposing  causes  in  tabes  of  inflammations  and  injuries 
of  the  bones  are  the  loss  of  sensibility — i.  e.,  the  anaesthesia  or  anal- 
gesia of  the  joints,  the  ataxia,  and  the  fragility  of  the  bones.  These 
factors  also  influence  very  materially  any  deforming  or  traumatic, 
acute  or  chronic  inflammation  occurring  in  a  person  suffering  from 
tabes  dorsalis.  The  softness  and  brittleness  of  the  bones  in  tabes  are 
well  known,  and  account  for  the  frequency  with  which  spontaneous 
fractures  take  place  in  patients  with  this  disease.  The  fragility  of  the 
bones  is  due  to  a  trophoneurotic  change  in  their  organic  ground  sub- 
stance, and  may  be  encountered  even  in  bones  which  are  apparently 
very  strong  and  compact.  The  bones  may  also  become  remarkably 
brittle  in  people  with  various  mental  diseases,  or  with  infantile  spinal 
j)aralysis,  progressive  muscular  atrophy,  leprosy,  etc.,  and  ISTeumann 
has  ascribed  the  changes  that  occur  to  an  affection  of  the  vasomotor 
system.  Czerny,  Rotter,  and  others  have  lately  made  exhaustive 
studies  of  arthropathia  tabidorum  and  neuropathic  bone  and  joint 
affections  in  general.  The  question  of  the  relationship  between  these 
affections  and  the  sclerosis  of  the  posterior  columns  of  the  cord  and 
other  diseases  of  the  spinal  cord  and  peripheral  nerves  has  recently 
been  the  subject  of  animated  discussion,  but  as  yet  it  has  not  been 
positively  decided  whether  spinal  diseases,  such  as  tabes,  syringomyelia, 
etc.,  should  be  regarded  as  direct  causes  of  these  troubles,  which  Char- 
cot believes  them  to  be,  or  only  as  predisposing.  Charcot  has  lately 
adopted  the  view  that  they  are  due  to  certain  localised  processes  of 
disease  in  the  diaphyses  and  epiphyses. 

Cause  of  Arthropathia  Tabidorum. — As  before  stated,  the  anaesthesia 
or  analgesia  of  the  joints  plays  a  most  important  part  in  the  produc- 
tion and  course  of  arthropathia  tabidorum.  The  neurojDathic  affections 
of  the  joints  which  occur  in  tabes  begin  either  without  any  external 
cause,  or  they  follow  the  reception  of  some  traumatism ;  and  as  the 
patients  feel  no  pain,  they  walk  about  while  their  joints  are  inflamed 
and  thus  make  matters  worse ;  they  wear  off  the  brittle  articular  ends 
of  the  bones,  as  it  were,  so  that  the  entire  astragalus,  for  example,  may 
by  degrees  completely  disappear.  A  tabetic  individual  with  a  fracture 
of  the  leg,  who  came  under  my  care,  could  produce  a  very  marked 
displacement  of  the  fragments  without  suffering  any  pain.  The  anal- 
gesia cannot  always  be  easily  recognised,  it  being  occasionally  limited 
to  the  more  deeply  situated  nerves  alone,  while  the  skin  is  even  over- 
sensitive to  the  slightest  irritation.  The  chronic  arthropathies  which 
occur  in  tabes  and  do  not  go  on  to  suppuration,  run,  as  a  rule,  a  course 
49 


722  INJURIES  AND  DISEASES  OF  JOINTS. 

similar  to  arthritis  deformans  (see  page  710),  but  differ  from  the  latter 
in  the  fact  that  the  different  parts  of  the  joints  are  very  rapidly 
destroyed,  and  dislocations  and  spontaneous  fractures  are  of  frequent 
occurrence.  One  can  distinguish,  as  in  arthritis  deformans,  an  atrophic 
and  a  hypertrophic  form  of  arthropathies  as  well  as  a  monarticular 
and  a  polyarticular  form.  If  the  specific  excitants  of  inflanmiation — 
micro-organisms — gain  entrance  to  a  joint  of  this  kind  which  is  the 
seat  of  a  chronic  inflammation,  septic  or  even  gangrenous  inflamma- 
tion running  a  very  rapid  course  ofter  develops.  Hence  it  can  be 
seen  that  in  the  course  of  tabes  various  forms  of  arthritis  may  be 
encountered,  some  acute  and  others  chronic,  and  either  suppurative  or 
non-suppurative ;  but  the  characteristic  feature  of  the  inflammation  is 
that  it  is  always  greatly  modified  and  influenced  by  the  analgesia  and 
ataxia  which  are  present,  and  by  the  weakness  and  fragility  of  the 
bones.  The  knee  is  the  joint  most  commonly  affected,  although  the 
articulations  of  the  upper  extremity  do  not  always  escape.  Rotter  has 
collected  112  cases  of  joint  disease  occurring  in  74  patients  with  tabes ; 
of  these,  49  were  of  the  knee,  24  of  the  hip,  12  of  the  shoulder,  12  of 
the  tarsal  joints,  6  of  the  elbow,  4  of  the  ankle,  3  of  the  hand  and 
fingers,  and  2  of  the  temporo-maxillary  joint.  Both  knee-joints  were 
diseased  in  11  cases,  both  hips  in  7,  the  tarsal  joints  in  3,  and  the 
shoulder,  wrist,  and  finger  joints  were  symmetrically  affected  twice. 
In  TVeizsacker's  statistics  of  109  cases,  72  occurred  in  men  and  37 
in  women.  The  knee-joint  was  affected  78  times,  the  hip  31,  the 
shoulder  21,  the  tarsus  13,  the  elbow  10,  the  ankle  9,  the  carpal  and 
temporo-maxillary  joints  twice,  and  the  vertebral  column  once.  The 
observations  of  Leyden,  Oppenheim,  and  others  show  that  affections  of 
the  joints  and  weakness  and  fragility  of  the  bones  may  occur  in  both 
the  earliest  and  the  most  advanced  stages  of  tabes  dorsalis. 

The  prognosis  of  the  tabetic  arthropathies  is  very  uncertain,  and 
depends  largely  upon  whether  the  joints  are  used  or  protected  and  prop- 
erly treated,  whether  ataxia  exists,  etc.  If  proper  treatment  is  received 
(fixation,  orthopaedic  appliances,  etc.),  it  is  possible  for  the  arthropathy 
to  be  improved  or  arrested. 

Similar  neuropathic  affections  of  the  bones  and  joints  are  also  noted 
in  the  course  of  other  cerebral  and  spinal  diseases— e.  g.,  acute  and 
chronic  myelitis — and  are  due  to  analogous  disturbances  of  innerva- 
tion. The  arthropathies  occurring  in  syringomyelia  are  particularly 
interesting.     Neuropathic  contractures  are  discussed  on  page  729. 

The  Arthropathies  of  Syringomyelia. — The  arthropathies  coming  on  in 
the  course  of  syringomyelia  mainly  attack  joints  of  the  upper  extremity,  for 
the  reason  that  the  primary  disease  is  for  the  most  part  localised  in  the  cer- 


§117.]  NEUROPATHIC  DISEASES   OF   BONES   AND  JOINTS.  ^23 

vical  portion  of  the  spinal  cord,  and  they  occur  in  the  great  majority  of  in- 
stances in  men  of  advanced  age.  Traumatisms  play  a  predisposing  part  in 
their  production.  The  course  of  the  arthropathies  is  always  chronic,  not 
infrequently  lasting  for  years.  There  will  occasionally  be  observed  an  acute 
exudation  in  the  joint,  or  even  suppuration,  especially  if  there  has  been  some 
injury  which  on  account  of  the  analgesia  has  been  neglected  ;  but  there  sel- 
dom occurs  such  a  marked  destruction  of  the  joint  in  a  comparatively  short 
time  as  in  tabes.  The  changes  in  the  joints  are  more  like  those  of  arthritis 
deformans,  with  the  formation  of  intra-articular  and  periarticular  osteo- 
phytes, with  ossification  of  the  periarticular  soft  partsf  degeneration  of  the 
muscles,  and  thickening,  dilatation,  and  relaxation  of  the  capsule,  with  sec- 
ondary spontaneous  dislocations.  The  joints  are  analgesic,  and  sometimes 
to  such  a  pronounced  degree  that  large  joints  can  be  resected  without  chloro- 
form (Czerny,  Sokoloffj.  This  analgesia  is,  moreover,  the  chief  factor  in 
furthering  the  development  of  the  disturbances  of  nutrition  which  are  pres- 
ent in  the  joints  and  bones.  The  bones  are  in  some  instances  abnormally 
weak  (hence  the  spontaneous  fractures)  and  in  others  remarkably  sclerotic. 
The  termination  of  the  arthropathies  which  occur  in  syringomyelia  is  gov- 
erned mainly  by  the  primary  disease  in  the  spinal  cord,  and  also  by  the 
amount  of  care  the  patient  takes  to  protect  his  joints  from  injuries  that  may 
readily  give  rise  to  complicating  periarticular  and  intra-articular  suppura- 
tion. Under  favourable  conditions  the  joint  affections  are  usually  very  pro- 
tracted. The  diagnosis  can  be  readily  made  if  the  pathological  changes  and 
the  clinical  course  are  taken  into  consideration  together  with  the  analgesia 
and  the  location  of  the  arthropathies  in  the  upper  extremity.  The  treatment, 
particularly  in  the  early  stages,  consists  in  immobilising  the  joint,  though 
later  on  suitable  operative  measures  may  be  necessary,  as  they  are  in  tabes. 

In  making  the  diagnosis  of  neuropathic  bone  and  joint  affections, 
the  characteristic  features  in  chronic  cases  are  the  existing  nervous  dis- 
orders, which  in  the  case  of  arthropathies  of  the  lower  extremity  is 
most  commonly  tabes,  and  of  the  upper  extremity  syringomyelia,  the 
analgesia,  the  pronounced  exudation,  and  the  marked  destruction  of  the 
articular  surfaces  of  the  bones ;  the  acute  cases  become  rapidly  worse. 
Czerny  is  right  in  calling  attention  to  the  fact  that  the  predisposition 
to  nervous  disorders  is  an  important  matter  from  a  medico-legal  stand- 
point— in  other  words,  should  be  taken  into  account  in  a  plaintiff  who 
brings  suit  for  damages. 

The  treatment  of  the  neuropathic  inflammations  of  joints,  particu- 
larly the  arthropathies  which  occur  in  tabes  and  syringomyelia,  com- 
prises proper  local  treatment  of  the  affected  joint  and  general  treat- 
ment of  the  neuropathy  which  is  the  primary  cause  of  the  trouble. 
We  consider,  as  Czerny  does,  that  firm  anchylosis  in  a  good  position  is 
preferable  to  a  loose  joint  which  is  rapidly  ground  down  by  friction,  and 
in  the  early  stages  it  would  be  proper  to  bring  about  artificial  anchylosis 
by  performing  arthrodesis  (see  page  139).     If  patients  with  the  above- 


724  INJURIES  AND  DISEASES  OF  JOINTS. 

mentioned  diseases  of  the  spinal  cord  receive  a  sprain,  the  joint  must  be 
treated  bj  immobilisation  and  subsequently  by  a  supporting  apparatus. 
Should  extensive  destruction  or  suppuration  of  the  joint  occur,  the 
question  of  arthrotomy,  resection,  or  amputation  would  arise. 

§  118.  Anchylosis. — By  anchylosis  (from  wyKvko^,  angular,  crooked) 
is  understood  an  immovable,  stiff  joint,  such  as  results  from  an  inflam- 
mation of  a  joint  which  has  run  its  course.  The  word  anchylosis  sig- 
nifies properly  an  angular  position  of  the  joint ;  but  this  conception  of 
the  term  has  in  course  of  time  been  entirely  given  up,  so  that  when  we 
speak  of  anchylosis  of  a  joint  we  mean  that  its  power  of  motion  has 
been  lost,  irrespective  of  whether  the  joint  has  become  fixed  at  an  angle 
or  in  a  straight,  extended  position.  If  a  joint  is  in  an  angular  position 
we  speak  of  it  as  a  contracture  (see  §  119).  Anchylosis — in  other 
words,  stiffness  of  the  joint — and  contracture  very  frequently  occur  in 
combination.  If  we  wish  to  differentiate  these  two  terms  more  exactly, 
we  may  say  that  aiichylosis  signifies  a  complete  cessation  of  the  motil- 
ity of  a  joint  brought  about  by  intra-articular  causes,  while  contracture 
is  a  limitation  of  motion  generally  due  to  pathological  changes  in  the 
extra-articular  soft  parts  (see  all  §  97  and  §  98,  Diseases  of  the  Nerves 
and  Muscles).  We  also  recognise  a  false  and  a  true  anchylosis  (anchy- 
losis spuria  and  anchylosis  vera).  The  term  false  anchylosis  applies  to 
those  cases  in  which  ajDparently  immovable  joints  can  be  caused  to 
move  under  chloroform  ansesthesia,  and  is  a  condition  which  is  observed 
in  the  course  of  acute  or  chronic  inflammations  of  joints  as  a  result 
of  inflaunnatory  or  voluntary  muscular  contraction,  or  in  hysterical 
joint  disorders,  etc. 

The  Causes  of  True  Anchylosis. — True  anchylosis  is  most  commonly 
due  to  the  development  of  a  firm  union  between  the  different  parts  of 
the  joint,  and  according  to  the  nature  of  the  tissue  forming  the  union 
between  these  parts  we  recognise  a  connective  tissue  (anchylosis  fibrosa), 
a  cartilaginous  (anchylosis  cartilaginea),  and  a  bony  anchylosis  (anchy- 
losis os>ea).  The  cicatricial  connective  tissue  which  develops  between 
the  opposed  articular  surfaces  in  the  healing,  for  example,  of  an  arthri- 
tis with  fungous  granulations,  either  takes  the  form  of  adhesions  which 
resemble  ligaments,  or  they  more  or  less  completely  fill  the  joint.  If 
ossification  of  the  connective  tissue  takes  place  it  is  possible  for  a  bony 
anchylosis  to  occur,  in  which  case  the  articular  ends  of  the  bones  are 
joined  together  by  an  osseous  bridge,  or  united  by  bone  throughout 
their  entire  extent.  Bony  anchylosis  may  develop  from  the  cartilagi- 
nous form,  or  it  may  arise  from  the  direct  coalescence  of  joint  sur- 
faces which  have  lost  their  covering  of  cartilage.  Cartilaginous  anchy- 
losis is  brought  about  by  a  growth  of  vascular  connective  tissue  between 


§  118.]  ANCHYLOSIS.  Y25 

the  opposed  surfaces  of  the  articular  cartilages,  and  if,  then,  this 
connective  tissue  disappears,  the  surfaces  of  the  cartilage  are  found  to 
have  coalesced  into  a  single  cartilaginous  mass.  Other  causes  of  stiff- 
ness in  joints  are  cicatricial  shrinkage  of  the  capsule  and  ligaments  of 
the  joint,  and  adhesions  between  two  opposed  portions  of  the  synovial 
membrane,  so  that  the  latter  can  no  longer  adapt  itself  to  the  move- 
ments of  the  different  portions  of  the  joint.  Anchylosis  may  also  be 
caused  by  proliferation  of  bone  or  cartilage  in  a  joint,  as  in  arthritis 
deformans,  or  by  the  development  of  bone  in  the  capsule  or  parts  sur- 
rounding the  joint,  which  sometimes  occurs  after  fractures  in  the 
neighbourhood  of  or  extending  into  a  joint.  Furthermore,  the  articu- 
lar ends  of  bones  may  be  so  altered  by  changes  such  as  occur  in  caries 
and  arthritis  deformans  that  they  do  not  fit  together,  and  so  are  not 
capable  of  performing  their  function  of  gliding  over  each  other  (anchy- 
losis of  deformity).  We  learned  in  a  previous  chapter  that  joints  may 
become  fixed  in  a  faulty  position  by  muscular  contractures,  or  by 
cicatricial  processes  in  the  muscles,  tendons,  tendon  sheaths,  bones,  etc. 

It  is  generally  an  easy  matter  to  make  the  diagnosis  of  anchylosis, 
but  in  doubtful  cases  chloroform  anaesthesia  may  be  required  to  deter- 
mine whether  the  anchylosis  is  false  or  true ;  it  is  also  the  best  way  of 
finding  out  how  much  motion,  if  any,  exists. 

Treatment  of  Anchylosis. — The  treatment  of  a  stiff  joint  includes 
both  an  attempt  at  restoration  of  its  motion  and  at  overcoming  the 
abnormal  position  in  which  the  joint  may  have  become  anchylosed  ;  in 
other  words,  one  should  strive  to  place  the  joint  in  such  a  position  that 
the  limb  may  be  more  or  less  useful  to  the  patient.  Only  in  rare 
instances  is  it  possible  to  restore  motion  in  a  joint  which  has  become 
fixed  by  true  anchylosis,  and  then  it  is  generally  accomplished  by 
resection.  But  we  can  very  often  prevent  an  anchylosis  from  taking 
place  by  employing  proper  treatment  for  the  diseases  and  injuries  of 
the  joints  and  the  parts  which  surround  them,  particularly  by  causing 
wounds  to  heal  aseptically,  and  after  the  subsidence  of  inflammation, 
by  using  massage  and  active  and  passive  motion.  If  in  the  course 
of  an  injury  or  inflammation  of  a  joint  we  are  unable  to  prevent 
an  anchylosis  from  developing,  we  must  always  place  the  joint  in 
that  position  which  will  render  it  most  useful  for  the  patient — the 
knee,  for  example,  in  extension,  the  ankle  and  elbow  at  a  right  angle, 
etc.  If  the  joint  has  already  become  fixed  in  a  distorted  position,  it 
may  be  possible  to  gradually  overcome  the  latter  by  massage  and  passive 
motion,  by  manual  correction  under  anaesthesia,  by  permanent  exten- 
sion by  a  weight,  by  the  use  of  frequently  applied  plaster-of- Paris 
dressings  or  splints  which  exert  pressure  or  traction,  or  by  operative 


726  INJURIES  AND   DlSExVSES  OF  JOINTS. 

division  of  the  contracted  periarticular  soft  parts,  especially  the  mus- 
cles, tendons,  and  fascia  (see  Tenotomy,  Myotomy,  page  580),  by  oste- 
otomy of  the  bone  in  the  neighbourhood  of  the  joint,  or  by  resection 
of  the  joint,  combined  possibly  with  the  removal  of  a  wedge  of  bone. 
Osteotomy  is  performed  either  in  the  form  of  simple  division  of  the 
bone  (see  §  26),  or  division  combined  with  the  removal  of  a  wedge- 
shaped  jiiece  from  the  continuity  of  the  bone.  Yolkmann's  method  of 
performing  linear  or  wedge-shaped  osteotomy  below  the  trochanter  of 
a  hip  which  has  become  anchylosed  has  yielded  excellent  results, 
improving  both  the  position  and  the  usefulness  of  this  joint.  In  some 
cases  the  joint  is  opened  (arthrotomy),  and  all  the  intra-articular  and  peri- 
articular adhesions  and  bands  which  prevent  the  movements  of  the  joint 
are  divided  (arthrolysis — Wolff),  without  resection  of  the  articular  ends. 
Resection  of  the  joint  (§  -iO),  and  in  desperate  cases  amputation  or  disar- 
ticulation (§  36  and  §  37),  are  also  operations  which  may  have  to  be 
resorted  to.  When  there  is  a  firm  anchylosis  due  to  fibi"ous,  cartilagi- 
nous, or  bony  union  between  the  articular  ends  of  the  bones,  combined 
with  a  contracted  position  of  the  joint,  arthrolysis  or  resection  are  gen- 
erally called  for,  the  object  being  the  formation  of  a  movable  joint,  or 
one  fixed  in  a  position  which  will  render  use  of  the  limb  possible.  In 
order  to  prevent  a  recurrence  of  the  anchylosis  a  celluloid  plate  or 
an  absorbable  membrane  of  animal  tissue  (hog's  bladder)  may  be 
inserted  between  the  joint  surfaces.  The  operation  of  arthrodesis  for 
obtaining  artificially  anchylosis  of  a  paralytic,  flail-like  joint  is  described 
in  §  40. 

§  119.  Deformities  of  Joints  (Contractures). — The  deformities  of 
joints  which  we  shall  speak  of  here  are  faulty  positions  in  which  joints 
may  have  become  more  or  less  fixed,  and  are 
sometimes  congenital  and  sometimes  acquired, 
and  when  acquired  are  called  contractures.  In 
discussing  the  subjects  of  inflammation  and 
anchylosis  of  joints  we  learned  how  contrac- 
tures might  develop,  and  consequently  we  shall 
/  ■  ^;%      confine  ourselves  at  present  merely  to  a  brief 

/-"'^^^'^  y  '<g       account  'oi  the  individual  forms  of  this  affec- 

W^P^n,  if        tion,  the  reader  being  referred  to  the  Regional 

^i^^^l^\.  7         Surgery  for   a   more   detailed   description   of 

^^^^^^--'^  "^  each,  especially  as  regards  the  treatment. 

Fig.  44S. — Club-foot   (pes  ^ni  ''     •,    ?    ^    c  •,•  i-     •    •     , 

varus).  ine   congemtal,   deiormities  oi   jomts   are 

mainly  due   to    disturbances   of   development 

which  occur  in  the  foetal  stage  of  life.     The  congenital  club-foot  (pes 

varus.  Fig.  448) — i.  e.,  the  supination-contracture  of  the  foot — is  an 


§  119.] 


DEFORMITIES   OF  JOINTS. 


727 


Fig.  449.— Club-foot  caused  by  a 
congenital  absence  of  the  entire 
tibia. 


example  of  this.  The  supination  is  almost  always  combined  with 
plantar  flexion  (pes  equino-varus).  It  might  be  said  that  a  slight 
amount  of  club-foot  is  physiological,  inas- 
much as  every  infant  at  birth  has  some 
suggestion  of  it.  Pronounced  club-foot  is, 
briefly  speaking,  a  disturbance  of  develop- 
ment in  the  astragalo-crural,  the  calcaneo- 
astragaloid,  or  the  astragal o-scaphoid  joints, 
which  is  brought  about  principally  by  the 
foot  being  kept  in  continuous  supination 
owing  to  lack  of  space  in  the  uterus.  The 
bone  which  undergoes  the  most  pronounced 
change  of  form  in  consequence  of  this 
continual  supination  of  the  foot  in  utero 
is  the  astragalus,  the  neck  of  which  be- 
comes longer  than  it  normally  should  be, 
and  somewhat  bent ;  in  other  words,  the 
growth  of  the  as- 
tragalus adapts  itself 

to  the  abnormal  position  which  the  foot  assumes 
in  utero.  The  rare  cases  of  congenital  flat-foot 
(pes  valgus  or  planus,  Fig.  452)  and  of  pes  cal- 
caneo-valgus  originate  in  a  similar  manner,  being 
due  to  the  pressure  exerted  by  the  walls  of  the 
uterus.  By  pes  calcaneo-valgus  is  understood  a 
foot  which  is  dorsally  flexed  to  such  an  extent 
that  its  dorsum  comes  nearly  or  quite  in  contact 
with  the  leg,  and  is  at  the  same  time  abducted 
(Fig.  455).  Scoliotic  or  kyphotic  curvatures  of 
the  spinal  column,  or  club-hand  or  club-foot, 
may  also  have  their  origin  in  congenital  defects 
occurring  in  the  vertebrae  or  in  the  bones  of  the 
forearm  or  (lower)  leg  (see  Fig.  449). 

The  acquired  deformities  of  joints  are  due 
first  of  all  to  disturbances  occurring  during  the 
growth  of  articular  surfaces  previously  normal, 
in  children  and  young  subjects.  Thus  deformi- 
ties of  the  joints  develop  in  the  lower  extremities 
and  vertebral  column  as  a  result  of  the  pressure 
exerted  by  the  weight  of  the  body.  Their  origin  is  to  be  ascribed  to 
pressure  on  the  joint  surfaces,  which  is  either  too  protracted  or  too 
excessive,  or  unevenly  distributed.     This  class  of  cases  includes  the 


Fig.  450.— Scoliosis. 


728 


INJURIES  AND  DISEASES  OF  JOINTS. 


Fig.  451.^Genu  valgum. 


lateral  curvatures  of  the  spiual  culuinu  or  scoliosis  (Fig.  450),  genu 
valgum  (Fig.  451),  and  flat-foot  (pes  planus  or  pes  valgus,  Fig.  452). 
Khachitic  bones  are  particularly  apt  to  suffer  from  these  pressure  de- 
formities ;  the  pressure  causes  a  grad- 
ual change  in  the  shape  of  the  bones, 
their  growth  beinff  diminished  in  the 
parts  where  the  pressure  is  greatest 
and  increased  where  the  pressure  is 
least.  The  diaphyses  or  epiphyses 
of  the  long  hollow  bones,  especially 
if  they  are  soft  (see  Rhachitis),  are 
thus  bent  and  curved  by  the  weight 
which  they  have  to  sustain.  This 
is  also  the  explanation  of  the  change 
in  the  shape  of  the  vertebrae  en- 
countered in  a  case  of  scoliosis  which 
has  existed  for  a  long  time,  and  of 
the  curvatures  of  the  femur  and 
tibia  in  the  neighbourhood  of  the 
junction  of  the  epiphysis  with  the 
diaphysis ;  of  the  obliquity  of  the 
condyles  in  genu  valgum  (Mikulicz) ;  and  of  the  depression  of  the  arch 
of  the  foot  and  change  in  shape  of  the  tarsal  bones  in  pes  valgus. 
Stretching  or  shortening  of  the  soft  parts,  especially  the  muscles,  fascia, 
and  the  ligaments  of  the  joint,  may  then  develop  secondarily.  "Wolff 
has  recently  combated  the  above  theory  of  the  mode  of  development 
of  bone  deformities,  viz.,  through 
pressure.     According  to  him,  the  de-    ^^  M 

formities  of  bones  are  to  be  regarded     ^  l| 

as  an  adaptation  to  a  pathologically  \ 
altered  function ;  the  changes  in  the 
external  form  of  the  bones  are  a  result 
of  their  internal  structure.  As  op- 
posed to  the  pressure  theory,  the  parts 
that  are  the  seat  of  pressure  show  an 
increased  growth  of  bone  correspond- 
ing to  the  "  trophic  stimulation  of  Fig.  452.— Fes  valgus. 
function  " — i.  e.,  the  bony  tissue  is  here 

thickened,  while  on  the  side  that  is  free  from  pressure  it  is  rarefied. 
I  consider  these  views  correct. 

As  a  result  of  primary  disease  of  the  muscles,  or,  more  commonly, 
of  the  nervous  system,  myopathic  and  neuropathic  deformities,  or,  in 


/ 


L 


> 


119.] 


DEFORMITIES  OF  JOINTS. 


729 


other  words,  true  contractures  of  joints,  are  produced.     Primary  mus- 
cular contractures  used  to  be  thought  very  common,  and  were  wrongly 
looked  upon  as  the   cause  of 
scoliosis  and  flat-foot. 

IS^europathic  contractures 
are  divided  into  the  spastic  and 
the  paralytic.  Spastic  contrac- 
tures are  the  result  of  diseases 
of  the  central  nervous  system, 
and  hence  belong  more  prop- 
erly to  the  province  of  internal 
medicine,  so  that  we  shall  con- 
fine ourselves  here  to  merely  a 
brief  description  of  them  in  so 
far  as  they  are  of  surgical  im- 
portance. Little  and  Erb  have 
recently  made  a  special  study 
of  this  form  of  contracture,  and 
have  shown  that  it  is  not  by 
any  means  as  rare  as  has  hith- 
erto been  supposed. 

Fig.  453.— Spastic  contracture  of  the  lower 

Spastic  Contractures— Spastic  extremities. 

Spinal  Paralysis.  —  Spastic  con- 
tractures are  observed  most  commonly  in  the  course  of*  spastic  spinal  paral- 
ysis, a  condition  which  is  characterised  by  spasm  of  the  muscles  and  in- 
creased reflexes,  and  is  caused  mainly  by  chronic  in- 
flammation (sclerosis)  of  the  lateral  pyramidal  tracts 
(Charcot,  Erb).  The  autopsies,  however,  have  not 
shown  a  pure  primary  degeneration  confined  to  the 
lateral  tracts,  and  it  is  hence  doubtful  whether  the 
spastic  spinal  paralysis  is  really  a  disease  sui  generis 
— i.  e.,  a  primary  degeneration  of  the  lateral  pyramidal 
tracts.  It  occurs  as  a  symptom  in  various  afi'ections 
of  the  central  nervous  system — e.  g.,  in  chronic  hydro- 
cephalus, cerebral  focal  diseases  with  secondary  degen- 
eration of  the  lateral  tracts,  hydromyelus,  slight  com- 
pression of  the  cord  above  the  lumbar  enlargement, 
spinal  meningitis,  after  sprains  of  the  cervical  verte- 
bree,  hysteria,  etc.  Among  etiological  factors,  syphilis, 
injuries  of  the  spine,  heredity,  etc.,  are  important.  The 
disease  occurs  most  commonly  in  adults  from  twenty 
to  fifty  years  of  age,  but  it  has  been  observed  in  chil- 
dren, and  even  as  a  congenital  affection  in  adults. 
The  symptoms  are  as  follows  :  At  the  outset  there  are  observed  a  slight 
fatigue  and  motor  weakness  of  the  lower  extremities,  which  become  affected 


Fig.  454. — Pes  equinus 
paralyticus. 


730 


INJURIES  AND  DISEASES  OF  JOINTS. 


Fig.  455. — Pes  calcaneus  paralyticus. 


simultaneously  or  one  after  the  other  ;  in  rare  cases  the  disease  begins  in  the 
arms.  The  legs  gradually  become  paralysed.  It  is  characteristic  that  the 
muscles  do  not  become  atrophied,  and  that  marked  symptoms  of  motor  irri- 
tation and  muscular  spasms  going  on  to  tetanic  contractures  make  their 
appearance  early.     The  tendon  reflexes  are  very  much  increased,  the  skin 

reflexes  remain  normal,  sensory  and  trojihic 
disturbances  are  slight  or  absent,  the  func- 
tions of  the  bladder  and  rectum  are  un- 
changed, and  ataxia  never  develops. 

The  spastic  gait  caused  by  the  muscular 
contractures  is  very  cliaracteristic.  Tlie 
legs  are  pressed  against  one  anotlier,  the 
patient  drags  them  after  him,  the  ends  of 
the  feet  hang  downward  and  are  used  as  a 
support,  the  body  is  bent  forward  sharply, 
and  there  is  a  marked  tendency  to  stumble 
and  fall.  In  consequence  of  the  spasm  of 
the  muscles  the  tendons  are  lengthened, 
and  the  bone  is  sometimes  thickened  at  the  point  of  insertion  of  the  tendons. 
Fig.  i53  represents  a  severe  case.  The  spastic  contractures  are  more  marked 
in  the  legs  than  in  the  arms.  The  paralysis  gradually  spreads  upward 
(paralysis  and  rigidity  of  the  muscles  of  the  back,  abdomen,  and  arms). 
The  cour.se  is  verj-  chronic.  The  prognosis  is  favourable  as  far  as  life  is  con- 
cerned, as  the  vital  functions  are  not  interfei^ed 
with,  but  the  disease  is  usually  inculpable,  al- 
though it  may  become  stationary  and  even  im- 
prove considei'ably.  The  treatment  includes  the 
use  of  galvanism,  hydrotherapy,  prolonged  baths 
at  26°  C.  (78°  F.),  and.  above  all,  orthopa?dic 
treatment  to  make  walking  possible.  The  ortho- 
pedic treatment  consists  in  straightening  out 
the  conti'actures  under  an  anaesthetic,  tenotomy 
of  certain  tendons,  followed  by  the  application 
of  plaster  splints,  and  the  use  of  orthopaedic 
appliances  for  practising  certain  movements. 
Massage  is  also  employed.  Tenotomy  not  only 
aids  in  straightening  the  limb,  but  it  also  has 
an  antispasmodic  effect.  Internally,  silver  ni- 
trate, ergotin,  potassium  iodide,  and  bromides  are 
given.  The  possibility  of  syphilis  or  a  previous 
traumatism  should  always  be  borne  in  mind.  Fig. 456.— -Claw position" (main 

Kii  fjriffe)  of  the  tingei-s  fol- 
_,,.-,.        ^  rm  1    j_-  lowing  paralysis  of  the  ulnar 

Paralytic    Contractures.  —  1  be    paralytic        nerve.' 
contractures — i.  e.,  those  which  are  the  result 

of  paralytic  conditions  and  follow  injuries  and  diseases  of  the  central 
nervous  system  and  peripheral  nerves — are  extremely  common  (see 
Eigs.  454,  455,  456).  They  include  the  paralytic  contractures  which 
occur  so  frequently  with  the  partial  or  total  paralyses  following  menin- 


§119.]  DEFORMITIES  OF  JOINTS.  731 

gitis  and  encephalitis  in  children,  and  the  spinal  (so-called  essential) 
infantile  paralyses  which  affect  almost  exclusively  the  lower  extremity. 
Of  the  paralytic  contractures  of  the  foot  the  most  common  are  the  pes 
equinus  paralyticus  (Fig.  454)  and  the  paralytic  club-foot  which  vei'y 
often  takes  the  form  of  pes  equino-varus  paralyticus.  In  the  paralytic 
club-foot  the  equinus  position  predominates,  but  in  the  congenital  form 
the  varus  contracture — i.  e.,  the  adduction  and  supination — is  the  most 
noticeable  feature  (Fig.  448).  The  pes  calcaneus  paralyticus  (Fig.  455) 
and  the  pes  valgus  paralyticus  (Fig.  452)  are  much  rarer.  Paralytic 
contractures  of  the  knee,  the  hip,  and  especially  of  the  hand,  where 
they  may  follow  injuries  of  the  ulnar,  median,  or  musculo-spiral  nerves, 
are  comparatively  common.  Fig.  456  illustrates  the  typical  main  en 
griffe,  or  claw  position,  assumed  by  the  fingers  after  paralysis  of  the 
ulnar  nerve.  In  the  region  of  the  spinal  column  paralytic  contractures 
take  the  form  of  lateral  curvatures  (paralytic  scoliosis)  or  of  flexion  or 
extension  contractures  (paralytic  kyphosis  and  lordosis).  In  all  cases 
paralysis  of  any  one  particular  group  of  muscles,  or  rather  of  the  nerves 
which  supply  them,  invariably  gives  rise  to  a  characteristic  contracture 
(see  Regional  Surgery,  §  294). 

Infantile  Spinal  Paralysis. — As  the  spinal  paralysis  of  children  often 
leads  to  paralytic  contractures,  it  should  be  briefly  described  at  this 
point.  The  disease  usually  attacks  children  between  one  and  four 
years  of  age.  The  acute  infectious  diseases  and  rheumatism  have  an 
important  etiological  bearing  upon  it,  and  heredity  is  sometimes  to  be 
taken  into  consideration.  Pathologically  it  is  an  acute  inflammatory 
process  situated  in  the  anterior  grey  horns  of  the  spinal  cord  (polio- 
myelitis acuta),  and  is  most  commonly  located  in  the  lumbar,  less  often 
in  the  cervical,  enlargement ;  it  is  either  unilateral  or  bilateral,  and  is 
characterised  by  hyperasmia,  by  haemorrhages,  and  by  red  softening 
with  degeneration  of  the  ganglion  cells  and  nerve  fibres.  This  inflam- 
matory process,  which  at  the  outset  is  acute,  results  in  the  development 
of  a  circumscribed  or  diffuse  sclerosis  (connective-tissue  growth)  with 
secondary  atrophy  of  the  nerve  fibres,  and  a  subsequent  secondary  de- 
scending degeneration  of  the  nerves.  The  muscles  supplied  by  these 
nerves  likewise  undergo  a  degenerative  atrophy,  and  in  addition  be- 
come the  seat  of  a  secondary  interstitial  growth  of  connective  tissue  or 
fat.  The  atrophy  of,  the  nerves  and  their  roots  is  a  secondary  change, 
and  that  of  the  muscles  is  a  result  of  the  loss  of  their  trophic  centres  in 
the  anterior  columns  of  grey  matter.  Leyden  states  that  the  affection 
may  also  result  from  a  peripheral  multiple  neuritis,  the  latter  in  part 
remaining  peripheral  and  in  part  leading  to  localised  disease  of  the 
spinal  cord. 


732  INJURIES  AND  DISEASES  OF  JOINTS. 

I  must  refer  the  reader  to  the  text-books  on  nervous  diseases  for  a 
full  description  of  the  symptomatology  of  infantile  spinal  paralysis,  as 
only  the  following  brief  outline  will  be  given  here.  The  disease  usu- 
ally begins  suddenly  without  prodromata,  with  a  high  fever,  40°  to  41° 
C.  (104°  to  105.8°  F.),  and  corresponding  acute  manifestations  accom- 
panied by  stupor,  convulsions,  etc.  Occasionally  this  acute  febrile  on- 
set is  absent.  After  one  or  two  days  the  acute  manifestations  generally 
disappear.  The  paralysis  develops  during  the  time  that  the  tempera- 
ture is  elevated,  but  is  usually  not  noticed  till  later.  It  spreads  at  first 
very  rapidly,  and  may  affect  all  the  mnscles  of  the  limbs  and  even 
those  of  the  trunk.  It  then  ordinarily  diminishes,  leaving  a  perma- 
nent paralysis  which  varies  greatly  in  extent,  but  is  generally  mono- 
plegic  and  confined  to  one  leg,  less  often  paraplegic,  and  still  more 
infrequently  takes  the  form  of  spinal  hemiplegia  or  of  crossed  spinal 
hemiplegia  (leg  and  arm  of  different  sides).  Often  only  parts  of  a 
limb,  or,  more  exactly,  only  certain  groups  of  muscles,  are  affected. 
The  permanent  paralysis  is  purely  motor,  and  is  characterised  by  a 
rapidly  progressing  atrophy  of  the  muscles.  Within  one  or  two  weeks 
the  f  aradic  excitability  is  lost,  though  at  the  outset  there  is  a  temporary 
increased  response  to  the  galvanic  current,  especially  to  the  positive 
pole.  There  are  to  be  noted,  in  addition  to  the  reaction  of  degenera- 
tion, the  absence  of  thfi  cutaneous  and  tendon  reflexes  in  the  region 
where  the  muscles  are  paralysed,  the  not  uncommon  hyperalgesia  of  the 
latter  on  pressure  and  their  steadily  increasing  atrophy,  and,  above  all, 
the  previously  mentioned  contractures  which  most  frequently  occur  in 
the  foot.     The  treatment  is  given  on  page  735. 

Infantile  Cerebral  Paralysis  {Spastic  Hemiplegia,  Acute  Poliencephali- 
tis — Striimpell). — Infantile  cerebral  paralysis,  which  occurs  chiefly  in  chil- 
dren from  three  to  four  years  of  age,  is  caused  by  lesions  in  the  motor  areas 
of  the  cortex  (inflammatory  changes  with  atrophy,  loss  of  tissue,  cicatrices). 
There  is  sometimes  a  diffuse  sclerosis  of  the  cortex,  atrophy  of  one  hemi- 
sphere, etc.  The  disease  is  also  congenital,  or  may  be  due  to  conditions 
occurring  during  birth.  The  same  etiological  factors  are  present  as  in  infan- 
tile spinal  paralysis.  The  onset  of  the  disease  is  acute,  with  fever  and  con- 
vulsions, vomiting,  and  usually  miconsciousness.  The  duration  of  this  ini- 
tial stage  varies  from  days  to  months.  Later  the  constitutional  disturbances 
disappear  and  the  paralysis  becomes  noticeable.  The  latter  is  generally  con- 
fined to  one  half  of  the  body  (with  exception  usually  of  the  face),  to  an  arm  or 
leg.  Sometimes  true  paralyses  are  not  present,  but  only  a  slight  limitation 
of  motion.  The  following  symptoms  are  characteristic  of  cerebral  paralysis : 
The  f aradic  contractility  of  the  paralysed  muscles  is  unchanged,  there  is  no 
reaction  of  degeneration,  the  sensation  and  temperature  of  the  skin  are  usu- 
ally normal,  and  the  tendon  reflexes  are  increased,  particularly  on  the  para- 
lysed side.     Contractures  of  the  paralysed   muscles  usually  appear  early. 


§  119.]  DEFORMITIES   OF  JOINTS.  733 

There  are  also  evidences  of  irritation  of  the  motor  centres  (athetosis,  severe 
twitching),  and  cortical  epilepsy,  either  in  the  form  of  a  local  spasm  of  the 
paralysed  muscles  without  loss  of  consciousness,  or  a  true  epileptic  attack  ; 
in  the  latter  case  the  convulsions  begin  in  the  pai^alysed  muscles  and  then 
become  general.  Mention  should  also  be  made  of  the  marked  disturbances 
in  the  growth  of  the  muscles  and  bones  on  the  paralysed  side.  In  some  cases 
there  are  mental  disturbances,  paralysis  of  the  bladder,  rectum,  etc. 

The  treatment  is  in  the  main  the  same  as  that  of  infantile  spinal  paralysis, 
and  is  principally  orthopaedic  (see  page  735). 

The  Manner  in  which  Contractures  Develop. — How  do  tlie  various 
paralytic  contractures  wliicli  occur  in  such  typical  forms  come  to  take 
place  ?  Delpech  was  of  the  opinion  that  thej  were  produced  by  active 
shortening  of  the  non-paralysed  antagonistic  groups  of  muscles,  and 
that  for  this  reason  the  contracture  took  place  towards  the  side  of  the 
antagonists.  But  Volkmann  and  Hueter  have  shown  that  this  antago- 
nistic theory  is  not  in  itself  sufficient  to  explain  the  manner  in  which 
paralytic  contractures  develop ;  that,  in  fact,  the  contracture  of  the  an- 
tagonists is  quite  commonly  absent,  and  that,  in  addition,  the  contrac- 
ture really  forms  in  the  direction  of  the  paralysed  group.  They  proved 
that  the  weight  of  the  limb,  and,  in  the  case  of  the  lower  extremity, 
the  superimposed  weight  of  the  body,  play  very  important  parts  in  the 
production  of  the  paralytic  contractures.  This  is  the  way  in  which  the 
pes  equinus  paralyticus  (Fig.  454)  develops,  since  the  foot  drops  down 
of  its  own  weight — in  other  words,  assumes  a  position  in  plantar  flex- 
ion, no  matter  whether  all  the  muscles  of  the  leg  below  the  knee  or 
only  the  extensors  are  paralysed.  This  equinus  position  of  the  foot 
may  also  result  from  a  paralysis  which  is  limited  to  the  muscles  of  the 
calf  alone,  for  the  reason  that  the  paralysed  muscles  undergo  a  shorten- 
ing from  lack  of  nutrition.  The  weight  of  the  paralysed  limb  can  like- 
wise he  shown  to  have  an  effect  upon  the  development  of  contractures 
in  other  joints  of  the  upper  and  lower  extremity. 

The  pressure  exerted  upon  the  paralysed  part  by  the  weight  of  the 
body  is  a  matter  of  importance  in  the  production  of  the  various  con- 
tractures which  may  occur  in  the  spinal  column  and  in  the  lower  ex- 
tremity when  the  affected  limb  is  used  for  standing  and  walking.  This 
partially  explains  the  way  in  which  the  paralytic  scoliosis  and  paralytic 
flat-foot  develop.  The  rare  deformity  known  as  pes  calcaneus  (Fig. 
455),  wdiich  is  usually  combined  with  a  valgus  position — i.  e.,  a  flatten- 
ing of  the  inner  border  of  the  foot — is,  according  to  Yolkmann,  caused 
by  a  tipping  forward  of  the  os  calcis,  due  to  the  latter  not  being  held 
firmly  enough  in  ]3osition  by  the  muscles  of  the  calf. 

The  diagnosis  of  paralytic  contractures  is  usually  easy,  and  can 
he  made  from  their  general  appearance,  without  an  electrical  exam- 


•34 


INJURIES  AND  DISEASES  OF  JOINTS. 


ination  (see  Injuries  of  Xerves,  Diseases  of  Xerves,  §  87,  §  88, 
and  §  97). 

The  pure  myopathic  contractures  due  to  primary  disease  of  muscles 
are  much  rarer  than  the  neuropathic,  and  result  from  certain  forms  of 
atrophy,  injury,  and  iniiammation  of  muscle  (see  §  98j. 

The  cicatricial  contractures,  especially  those  due  to  loss  of  substance 
in  the  skin  and  subcutaneous  soft  parts  following  acute  and  chronic 
inflammations  of  the  soft  parts  and  joints,  have  already  been  sufliciently 
described  in  the  chapters  on  Healing  of  Wounds  (§  61)  and  on  Injuries 
and  Inflammations  of  the  Soft  Parts  (§§  87-100). 

We  have  thus  gained  an  understanding  of  the  numerous  causes 
which  give  rise  to  contractures,  and  can  now  distinguish  two  main 
groups  of  those  which  involve  joints,  basing  the  classification  upon  the 


Fig.  457. — Contracture  of  the  hip-joint  in  coxitis  from  shrinkage  of  the  fascia  lata. 


manner  in  which  they  originate ;  these  are,  (1)  arthrogenic  contrac- 
tures resulting  from  congenital  or  acquired  changes  in  the  parts  whicli 
constitute  the  joint,  and  (2)  non-arthrogenic  contractures  due  to  patho- 
logical changes  in  the  neighbourhood  of  the  joint,  or  to  other  diseases, 
especially  those  of  the  nervous  system.  The  neurogenic,  myogenic, 
and  tendogenic  contractures  which  follow  diseases  or  injuries  of  the 
nerves,  muscles,  or  tendons,  or  are  brought  about  by  shrinkage  of 
fascia,  etc.,  belong  to  the  non-arthrogenic  class.  The  cicatricial  con- 
tractures which  follow  losses  of  substance  from  traumatism  or  inflam- 
mation, or  are  the  result  of  adhesions,  may  occur  in  any  part  of  the 
body.  Contractures  of  joints  are  sometimes  produced  by  causes  whicli 
are  partly  arthrogenic  and  partly  non-arthrogenic,  as,  for  example,  in 
chronic  inflammations  of  the  hip  (coxitisi,  where  there  develops  along 
with  the  inflammation  a  progressive  shrinkage  of  the  fascia  lata,  unless 
this  is  prevented  by  proper  treatment  (Fig.  457).     Muscular  contrac- 


§  119.]  DEFORMITIES  OF  JOINTS.  735 

tures  in  diseases  of  joints  are  also  very  frequently  caused  by  reflex 
action,  as  described  on  pages  569  and  575. 

Treatment  of  Deformities  and  Contractures  of  Joints. — The  treatment 
of  very  many  of  the  deformities  and  contractures  of  joints  belongs 
really  to  the  province  of  orthopaedic  surgery,  which  has  made  great 
progress  in  the  last  few  years.  It  would  require  too  much  space  to 
describe  at  length  the  treatment  of  each  separate  deformity,  but  it  will 
suffice  to  say  here  that  in  general  the  treatment  consists  in  the  use  of 
immobilising  dressings  (plaster  of  Paris,  extension),  supporting  appara- 
tus, operative  measures  (osteotomy,  tenotomy,  myotomy),  electricity, 
massage,  and  gymnastics.  The  treatment  of  cicatricial  contractures 
which  have  resulted  from  inflammation  and  injury  of  the  soft  parts 
has  already  been  spoken  of  in  connection  with  Injuries  and  Inflamma- 
tions of  the  Soft  Parts  (§§  87-100),  and  the  treatment  of  arthrogenic 
contractures  has  been  given  in  connection  with  Inflammations  and 
Anchylosis  of  Joints  (§§  113-118). 

The  treatment  of  infantile  spinal  paralysis  consists  in  the  use  of 
massage,  electricity,  and  a  strengthening  mode  of  life.  A  weak  gal- 
vanic current  should  be  applied  to  the  spinal  cord  as  early  as  possible, 
by  placing  one  of  the  large  flat  electrodes  over  the  portion  which  is 
supposed  to  be  the  seat  of  the  disease,  and  the  other  electrode  on  the 
anterior  surface  of  the  trunk,  and  then  alternating  the  action  of  the 
anode  with  that  of  the  cathode.  In  addition,  the  muscles  themselves 
are  treated  with  weak  faradic  or  galvanic  currents,  and  massaged,  or 
rubbed  with  alcohol.  Baths  (hot  baths,  salt  baths,  sea  baths,  etc.)  are 
useful,  as  well  as  other  hydrotherapeutic  measures ;  also  the  internal 
administration  of  the  iodide  of  potassium,  nitrate  of  silver,  ergotine, 
iron,  strychnine,  cod-liver  oil,  and  flnally  good  air  and  nourishing  food. 
Supporting  apparatus  or  immobilising  dressings  should  be  used  to  pre- 
vent the  occurrence  of  deformities,  especially  in  the  lower  extremities. 
In  suitable  cases  (e.  g.,  in  paralytic  pes  valgus,  pes  equinus,  etc.)  the 
transplantation  of  tendons  is  employed  ;  the  paralysed  muscles  or  ten- 
dons are  sutured  into  non-paralysed  ones,  and  the  function  of  the  for- 
mer is  thus  restored.     See  also  page  481  and  the  Regional  Sui'gery. 

The  treatment  of  infantile  cerebral  paralysis  is  in  the  main  the 
same  as  that  of  the  spinal  form. 

The  treatment  of  spastic  spinal  paralysis  has  already  been  spoken 
of  on  page  730. 

In  order  to  prevent  or  correct  deformities,  it  is  a  good  plan  to  use 
plaster-of-Paris  dressings  or  suitable  orthopsedic  contrivances.  Ten- 
otomy is  often  of  great  value ;  it  not  only  corrects  deformity,  but  acts 
directly  as  an  antispasmodic  measure. 


736  INJURIES  AND  DISEASES  OF  JOINTS. 

§  120.  Injuries  of  Joints. — Injuries  of  joints  are  divisible  into  two 
main  groups,  {1}  subcutaneous  and  (2)  open.  Tlie  latter  are  also  called 
penetrating,  as  they  enter  the  joint-cavity.  AVe  shall  lirst  take  up  con- 
tusions of  joints. 

Joint  Contusions. — Contusions  resulting  from  a  blow  with  some 
blunt  instrument,  or  from  a  fall,  are  the  mildest  form  of  injury  to  a 
joint.  The  contusions  may  be  direct  or  indirect,  depending  upon 
whether  the  violence  which  causes  the  injury  acts  directly  upon  the 
joint,  or  indirectly  by  contre  coup.  Indirect  contusions  of  the  hip,  for 
example,  are  caused  by  a  fall  upon  the  feet  or  upon  the  trochanter.  In 
indirect  contusions  the  principal  injury  is  a  greater  or  less  amount  of 
bruising  of  the  articular  surfaces  brought  about  by  the  latter  being 
forced  against  one  another,  and  in  the  worst  cases  a  fracture  may  occur 
with  impaction  of  the  fragments ;  but  in  direct  contusions  it  is  mainly 
the  surrounding  soft  parts  and  the  synovial  membrane  which  are 
injured. 

The  most  important  symptom  of  a  contusion  of  a  joint  is  the 
effusion  of  blood  into  the  latter — the  hsemarthros — which  is  in  some 
cases  slight,  in  others  very  marked,  so  that  the  joint  feels  tense.  The 
blood  coagulates  in  a  joint  very  quickly,  but  the  clots  soon  dimin- 
ish in  amount — i.  e.,  they  are,  as  it  were,  dissolved  by  the  synovial 
fluid,  so  that  in  twenty-four  hours  after  the  accident  there  is  a  viscid, 
bloody  collection  in  the  joint,  which  is  readily  absorbable  by  the  lym- 
phatics of  the  synovial  membrane  ( Jaffe).  If  the  joint  is  filled  to  its 
utmost  limits  it  becomes  slightly  flexed,  as  this  position  renders  it  most 
relaxed  and  gives  it  its  greatest  capacity.  The  effusion  of  blood  is, 
of  course,  most  easily  made  out  in  joints  like  the  knee,  which  are 
superficially  situated.  In  haemophilia  and  scurvy  an  effusion  sometimes 
occurs  spontaneously,  or  as  a  result  of  very  slight  injuries.  Other 
symptoms  of  joint  contusions  are  an  infiltration  of  the  skin  and  the 
subcutaneous  soft  parts  with  blood,  especially  if  the  contusion  is  direct ; 
pain  in  the  joint,  which  is  usually  slight,  but  made  worse  by  move- 
ment; and  disturbance  of  function,  varying  with  the  amount  of  blood 
which  is  effused.  For  the  symptoms  caused  by  a  fracture  of  the  bony 
parts  of  a  joint  the  reader  is  referred  to  §  101  (Fractures). 

The  subsequent  course  of  a  contusion  of  a  joint  which  is  not  com- 
plicated by  a  fracture  is,  as  a  rule,  favourable,  and  complete  recovery 
usually  follows  in  a  short  time,  though  occasionally  slight  inflammatory 
symptoms,  or  hydarthros,  persist  for  a  good  while.  It  is  only  in  very 
exceptional  instances  that  suppuration  takes  place  within  the  joint, 
from  a  suppurative  process  which  originates  in  a  laceration  of  the  skin, 
gradually  extends  to  the  deeper  parts,  and  finally  involves  the  articula- 


§  121.]  SPRAINS.  737 

tion.  Suppuration  of  the  efEusion  of  blood,  due  to  micro-organisms 
which  are  deposited  by  the  circulating  blood,  is  extremely  rare,  but 
in  a  tubercular  or  scrofulous  person  a  tubercular  inflammation  not 
infrequently  results  from  a  contusion  or  sprain  of  a  joint. 

The  diagnosis  of  contusion  can  usually  be  easily  made  from  the  swelling 
of  the  joint  coming  on  after  a  traumatism,  from  the  fluctuation,  the  pain  on 
movement,  and  the  more  or  less  marked  loss  of  function.  The  effusion,  if 
sufficient  in  amount,  assumes  the  outward  conflgui'ation  of  the  joint.  The 
possibility  of  haemophilia,  as  well  as  of  fracture,  should  always  be  thought 
of,  and  as  careful  an  examination  as  possible  made  with  these  in  view. 

The  treatment  of  joint  contusions  consists  in  the  employment  of 
massage  at  an  early  period,  in  order  to  get  rid  of  the  effusion  by  press- 
ing it  into  the  interstices  between  the  tissues  and  by  causing  it  to  be 
absorbed  by  the  lymphatics.  Pressure  applied  to  the  joint  by  means  of 
elastic  bandages,  and,  above  all,  repeated  movements  of  the  joint,  also 
promote  the  absorption  of  the  blood.  In  this  way  joint  contusions  are 
made  to  get  well  very  rapidly,  and  even  very  large  effusions  will  dis- 
appear in  a  few  days  if  massage  is  begun  as  soon  as  possible  after  the 
accident.  Contusions  of  joints  used  to  be  treated  by  keeping  the  joint 
at  rest  and  by  applying  ice.  Ice  is  seldom  necessary,  and  then  only  in 
the  first  stages,  to  soothe  the  pain ;  but  keeping  the  joint  at  rest  is 
actually  harmful  in  typical  cases  uncomplicated  by  a  fracture,  as  the 
organisation  of  the  effusion  into  connective  tissue  is  thus  materially 
helped.  Puncture  and  antiseptic  irrigation  of  the  joint  (see  page  692) 
are  only  necessary  when  the  joint  is  distended  to  its  utmost  capacity. 
Por  the  treatment  of  a  hydarthros  or  suppuration  of  a  joint  which  may 
follow  a  contusion,  the  reader  is  referred  to  §§  113, 114.  A  subcutane- 
ous fracture  within  a  joint  is  treated  according  to  the  rules  laid  down 
on  page  621. 

§  121.  Sprains  {Distortions). — By  a  sprain  or  distortion  we  mean  a 
momentary  forcible  stretching  and  twisting  of  a  joint,  usually  combined 
with  a  laceration  of  certain  portions  of  its  capsule  and  ligaments.  At 
present  we  shall  omit  all  mention  of  the  severe,  complicated  lacerations 
which  are  accompanied  by  opening  of  the  interior  of  the  joint,  as  we 
shall  return  to  these  injuries  under  the  subject  of  Penetrating  Wounds 
of  Joints,  and  shall  confine  ourselves  here  simply  to  a  description  of 
the  typical  subcutaneous  sprains  or  distortions  which  occur  with  such 
great  frequency. 

Besides  the  stretching  and  tearing  of  the  capsule  and  ligaments  of 
the  joint  and  the  periarticular  soft  parts  which  we  have  just  men- 
tioned, there  also  occurs  a  temporary  change  in  the  normal  position  of 
the  articular  ends  of  the  bones — a  momentary  partial  dislocation,  as  it 
50 


738  INJURIES  AND  DISEASES  OF  JOINTS. 

■^ere — but  as  soon  as  the  force  has  ceased  to  act  they  return  to  their 
proper  position.  Sprains  are  usually  caused  by  the  same  sort  of  vio- 
lence as  dislocations  (see  §  122)— i.  e.,  by  forced  movements  which 
are  carried  beyond  the  physiological  limits,  or  which  are  at  variance 
with  the  normal  mechanism  of  the  joint.  The  amount  of  force  applied 
in  causing  sprains  is,  however,  not  sufficient  to  Ijring  about  a  more 
than  temporary  separation  of  the  articular  ends  of  the  bones,  and  only 
a  stretching  or  partial  tearing  of  the  capsule  and  ligaments  takes  place, 
though  in  the  severest  cases  these  structures  may  be  completely  rup- 
tured. Sprains  of  the  wrist  are  usually  the  result  of  hyperextension, 
hyperflexion,  or  torsion  of  the  hand,  and  those  of  the  ankle  of  forced 
pronation  or  supination  of  the  foot.  Simultaneously  with  sprains  of 
the  joint  the  neighbouring  muscles  and  tendons  are  of  course  often 
stretched  and  lacerated,  but  a  partial  or  complete  rupture  of  the  mus- 
cles and  tendons  or  dislocation  of  the  latter  is  only  observed  in  rare 
instances.  Injuries  of  bones,  consisting  in  contusions  of  their  articu- 
lar ends,  or  in  tearing  or  chipping  ofi  portions  of  them,  are  common 
occurrences  in  distortions.  Examples  of  such  injuries  are  fractures  of 
the  fibula  or  internal  malleolus  in  sprains  of  the  ankle,  fractures  of  the 
lower  end  of  the  radius  in  sprains  of  the  wrist,  and  cortical  tear- 
fractures  {Biss-fracturen)—\.  e.,  the  tearing  away  of  pieces  of  bone 
which  form  the  points  of  insertion  of  ligaments  and  tendons.  I 
should  not  omit  mentioning  the  dislocations  of  interarticular  cartilages 
which  may  take  place — the  semilunar  fibro-cartilages  of  the  knee,  for 
example — in  sprains  of  the  latter  joint. 

The  symptoms  of  a  sprain  consist  mostly  in  a  very  intense  pain,  in 
consequence  of  which  the  active  function  of  the  joint  is  disturbed,  the 
joint  becoming  completely  powerless  and  as  though  paralysed.  There 
is  usually  a  diffuse  swelling  of  the  joint,  caused  by  the  intra-articnlar 
and  periarticular  effusion  of  blood,  and  if  a  fracture  is  present  at  the 
same  time  this  effusion  is  very  marked.  Later,  owing  to  changes  in 
the  colouring  matter  of  the  blood  situated  in  the  skin  and  subcutaneous 
tissue,  bluish-red,  bluish-green,  dark  yellow  or  yellow  discoloration s 
make  their  appearance.  The  subsequent  coui-se  of  sprains  in  typical 
cases  is  usually  favourable,  and  as  a  rule,  if  proper  treatment  is  adopted, 
they  get  well  very  rapidly.  In  cases  complicated  by  a  fracture,  the 
final  outcome,  especially  as  regards  restoration  of  the  function  of 
the  joint,  is  dependent  upon  the  nature  and  location  of  the  break  in 
the  bone.  Complicated  cases  of  sprain  may  occasionally  give  rise  to 
chronic  deforming  inflammations  of  the  joint,  which  obstinately  resist 
every  form  of  treatment.  In  other  instances  anchylosis  may  develop, 
or  the  opposite  conditions  may  be  encountered,  the  articulation  becom- 


§123.]  DISLOCATIONS   OF  JOINTS.  739 

ing  loose  and  flail-like  from  the  stretching  and  displacement  of  its 
various  constituents,  so  that  subluxations,  or  partial  dislocations  of 
joints,  like  the  wrist,  knee  (genu  valgum),  or  ankle  (flat-foot),  may 
result.  The  consequences  which  may  ensue  from  an  unrecognised 
rupture  of  a  tendon  or  separation  of  the  latter  from  its  point  of  attach- 
ment are  also  worthy  of  consideration.  Sprains,  like  contusions,  are 
only  followed  by  acute  suppuration  of  the  joint  in  very  exceptional 
instances  ;  but  not  infrequently  predisposed  individuals  may  subse- 
quently acquire  a  tubercular  arthritis  in  a  joint  which  has  been  the 
seat  of  a  distortion. 

The  diagnosis  of  sprains  can  be  easily  made  from  what  has  been 
said ;  but  the  joint  should  always  be  carefully  examined  for  fracture, 
especially  when  the  injury  is  near  the  hand  or  foot. 

The  treatment  of  subcutaneous  sprains  which  are  not  complicated 
by  a  fracture  is  essentially  the  same  as  that  of  a  contusion  of  a  joint,  and 
consists  in  early  massage,  intermittent  bandaging  of  the  joint  with  an 
elastic  bandage,  and  the  use  of  methodical  movements.  Antiphlogesis 
is  very  frequently  not  necessary,  or  at  most  only  in  the  first  few  hours 
or  days.  Massage,  in  cases  not  complicated  by  a  fracture,  frequently 
seems  to  act  in  a  marvellous  Avay,  and  a  joint  which  is  still  perfectly 
stiff  and  without  function  may  again  be  made  capable  of  active  motion 
and  of  performing  all  its  functions  by  massaging  it  only  once.  The 
sooner  massage  is  begun  the  better.  Kest  and  immobilisation  in 
uncomplicated  cases  are  to  be  condemned.  If  a  fracture  is  present, 
it  should  of  course  be  treated  according  to  the  general  principles  which 
apply  to  it.  In  the  rare  cases  of  complete  rupture  of  the  tendons  or 
capsule,  the  joint  must  likewise  at  first  be  immobilised  until  the  tears 
in  these  structures  have  united.  If  tendons  have  been  ruptured,  their 
ends  may  ultimately  have  to  be  joined  together  by  catgut  sutures. 
Other  complications,  such  as  suppurative  arthritis — which  very  rarely 
occurs — are  to  be  treated  in  the  usual  way.  Puncture  and  antiseptic 
irrigation  of  the  joint,  on  account  of  extreme  distejition  of  the  latter 
with  blood,  are  called  for  only  in  exceptional  instances. 

§  122.  Dislocations  (Luxations)  of  Joints. — By  a  dislocation  is  meant 
a  permanent  displacement  of  the  articular  ends  of  two  or  more  of  the 
bones  making  up  the  joint.  Dislocations  are  complete  or  incomplete, 
the  latter  also  being  called  subluxations.  In  confiplete  dislocations  the 
opposed  joint  surfaces  are  entirely  separated  from  one  another,  while 
in  the  incomplete  variety  the  articular  ends  are  still  partially  in  con- 
tact. The  dislocations  of  amphiarthroses  like  the  symphysis  pubis  are 
usually  called  diastases.  A  distinction  is  also  made  between  recent 
and  old,  and  between  simple  and  complicated  or  compound  disloca- 


740  INJURIES  AXD   DISEASES  OF  JOINTS. 

tious.  The  latter  include  those  especially  which  are  associated  with 
open  wounds  in  the  soft  parts,  vrith  ruptures  of  large  vessels  or  nerves, 
or  with  fractures. 

As  regards  the  causation  of  dislocations,  we  distinguish  (1)  the  trau- 
matic, due  to  external  violence,  (2)  the  spontaneous,  pathological,  or 
inflammatorj  dislocations  which  occur  in  the  course  of  an  inflamma- 
tion in  a  joint,  and  (3)  the  congenital  dislocations. 

I.  Traumatic  Dislocations. — Traumatic  dislocations  are  almost  al- 
ways the  result  of  external  violence,  rarelv  of  excessive  muscular  ac- 
tion. The  force  is  usually  applied  indirectly,  so  that  the  bones  are 
separated  from  one  another  by  leverage,  the  power  being  exerted  at  a 
greater  or  less  distance  from  the  joint.  Thus,  as  a  rule,  forced  move- 
ments are  caused  to  take  place  which  go  beyond  the  physiological 
limits  of  flexion,  extension,  abduction,  adduction,  pronation,  or  supi- 
nation, or  movements  are  produced  which  are  at  variance  with  the 
normal  mechanism  of  the  joint,  particularly  forced  rotation.  In  every 
joint  there  exists  a  mechanism  for  checking  its  motion  ;  this  is  gener- 
ally made  up  of  bone,  less  often  of  the  ligaments  or  capsule  of  the 
articulation.  TVhen  a  dislocation  takes  place  this  natural  inhibitory 
mechanism  is  overcome,  and  the  articular  end  of  the  bone  is  pressed 
against  this  check  to  its  further  movement,  which  then  becomes  the 
fulcrum.  If  the  force  ceases  to  act  at  this  stage,  the  articular  ends  of 
the  bones  return  to  their  normal  position  of  contact  with  one  another, 
and  only  a  sprain  is  the  result ;  but  if  the  force  keeps  on  acting,  one 
of  the  articular  surfaces  is  lifted  from  the  other,  the  capsule  ruptures, 
the  ligaments  and  muscular  insertions  which  resist  are  stretched  or 
likewise  ruptured,  and  the  articular  end  of  the  bone  escapes  either 
partially  or  completely  from  the  capsule. 

In  a  dislocation  of  the  elbow  from  over-extension,  the  olecranon 
fossa  acts  as  the  fulcrum  against  which  presses  the  tip  of  the  olec- 
ranon process.  At  the  hip  the  rim  of  the  acetabulum  is  the  ful- 
crum. The  point  where  the  displaced  articular  end  of  the  bone 
finally  comes  to  rest  depends  upon  the  nature  of  the  movement  and 
the  amount  of  force  brought  to  bear.  After  the  force  which  pro- 
duces the  injury  has  ceased  to  act,  the  dislocated  articular  end  of 
the  bone  is  made  to  assume  some  particular  position  by  a  so-called 
secondary  Tnovement^  brought  about  by  the  elasticity  of  the  soft  parts 
— skin,  ligaments,  capsule,  and  muscles.  In  this  the  weight  of  tlie 
limb  and  the  movements  made  by  the  injured  person  or  by  others 
are  also  to  be  taken  into  consideration.  The  dislocated  articular  end 
of  the  bone  is  held  in  its  new  ];)05ition  mainly  by  means  of  the  unin- 
jm^ed  portions  of  the  capsule  and  accessory  ligaments.     The  disloca- 


§122.]  DISLOCATIONS ,  OF  JOINTS.  Y41 

tions  caused  by  direct  violence,  such  as  a  blow  or  fall  upon  the  joint, 
are  much  rarer. 

Occasionally  dislocations  result  from  muscular  action,  especially  at 
the  shoulder  (Cooper,  Streubel,  etc.),  where  they  have  been  caused  by 
making  attempts  to  seize  an  object  placed  above  the  head,  or  by  pull- 
ing with  the  hand  elevated.  The  dislocations  of  the  lower  jaw  due  to 
opening  the  mouth  too  wide,  as  in  yawning,  are  also  j)roduced  by  mus- 
cular action  ;  and  dislocations  following  general  muscular  contractions, 
as  in  epilepsy  or  eclampsia,  belong  to  the  same  category. 

Many  persons  can  dislocate  their  joints  voluntarily  ;  but  these  dis- 
locations— that  of  the  first  phalanx  of  the  thumb  being  a  common  ex- 
ample— are  not  ordinarily  complete,  though  in  some  instances  they 
may  be.  The  well-known  athlete  "VYarren  was  able  at  will  to  com- 
pletely dislocate  most  of  his  joints,  including  the  shoulder  and  hip, 
and,  in  the  case  of  the  latter,  to  cause  the  head  of  the  femur  to  lie 
two  inches  above  Nelaton's  line.  Then,  when  he  wished,  he  could 
reduce  it  again,  causing  a  loud,  snapping  sound.  Acrobats  and  so- 
called  "  snake  men "  bring  about  by  constant  practice  such  a  length- 
ening and  loosening  of  the  capsule  and  ligaments  of  their  joints  that 
they  can  finally  dislocate  the  latter  and  bring  them  back  into  place 
again  voluntarily. 

Occurrence  of  Traumatic  Dislocations.— Dislocations  are  most  common  in 
middle  life,  and  are  very  rare  in  old  people  and  young-  children,  for  the  reason 
that  external  violence  is  more  likely  to  cause  their  bones  to  break.  Young- 
children  are  very  apt  to  sustain  sei^arations  of  the  epiphyses  owing  to  the 
slight  powers  of  resistance  which  the  latter  possess.  Dislocations  of  the 
upper  extremity  are  the  most  common,  amounting,  according  to  Kronlein, 
to  92.3  per  cent,  of  all  luxations,  while  dislocations  of  the  lower  extremity 
amount  to  only  5  per  cent.,  and  those  of  the  trunk  to  only  2.8  per  cent.  Dis- 
locations of  the  shoulder,  on  account  of  the  freedom  of  motion  in  this  joint, 
are  the  most  common,  constituting  about  one  half  of  all  the  dislocations 
which  are  encountered  (51.7  per  cent.,  Kronlein).  Dislocations  occur  from 
three  to  five  times  more  frequently  in  men  than  in  women,  because  the  for- 
mer are  more  exposed  to  injuries  on  account  of  their  occupations.  Disloca- 
tions of  the  lower  jaw  are.  however,  according  to  Kronlein,  about  four  times 
more  common  in  women  than  they  are  in  men. 

The  anatomical  changes — i.  e.,  the  amount  of  injury  to  the  tissues — de- 
pend in  general  upon  the  nature  and  intensity  of  the  force  which  is  brought 
to  bear  and  the  anatomical  structure  of  the  joint  in  question.  As  a  rule, 
however,  the  following  injuries  to  the  tissues  are  more  or  less  constant :  The 
rent  in  the  capsule,  which  is  always  present  in  a  complete  traumatic  disloca- 
tion, is  sometimes  slit-shaped  and  sometimes  irregular  in  form ;  not  infre- 
quently the  capsule  is  torn  from  its  insertion,  and  may  or  may  not  carry 
with  it  at  the  same  time  a  portion  of  the  bone  to  which  it  is  attached.  The 
accessory  ligaments  are  either  stretched,  lacerated,  completely  ru^Dtured,  or 


742 


INJURIES  AND  DISEASES  OF  JOINTS. 


torn  from  their  point  of  insertion  on  tlie  bone.     Similar  changes  take  pU^ce 
in  the  muscles.     The  intra-articular  and  periarticular  efiPusion  of  blood  is 

usually  not  very  large,  and  when 
it  is,  a  fracture  may  be  suspected. 
The  most  important  complications 
of  traumatic  dislocations  are  exten- 
sive injury  to  the  skin  and  subcuta- 
neous soft  parts,  the  simultaneous 
presence  of  a  fracture,  and  injuries 
to  lai'ge  vessels,  nerves,  and  internal 
organs. 

In  the  majority  of  cases  of  un- 
complicated dislocations,  after  reduc- 
tion of  the  displaced  articular  sur- 
faces has  been  accomplished,  a  com- 
plete restitutio  ad  integrum  usually 
follows,  the  rent  in  the  capsule  ap- 
pearing to  heal  with  especial  rapid- 
ity. But  if  the  dislocated  articular 
end  of  the  bone  remains  in  its  ab- 
normal position  a  new  more  or  less 
perfect  joint  is  formed — a  so-called 
nearthrosis  (see  Figs.  458, 447).  These 
nearthroses  are  sometimes  very  per- 
fectly developed,  especially  at  the 
hip  and  shoulder.  As  illustrated  in 
Fig.  458,  a  new  socket  is  formed  at 
the  hip  by  growth  of  the  periosteum,  which  becomes  covered  with  hyaline 
or  fibrous  cartilage.  The  capsule  is  constructed  by  an  inflammatoiy  new 
formation  of  tissue  in  the  surrounding  soft  parts,  and  its  inner  surface  is 
gradually  made  smooth  by  the  movements  of  the  head  of  the  bone,  so  that  it 
may  finally  come  to  resemble  a  synovial  membrane.  The  dislocated  end  of 
the  bone  usually  atrophies  somewhat,  and  changes  take  place  in  its  articular 
surface  corresponding  to  the  new  conditions  of  friction ;  these  changes  are 
sometimes  similar  to  those  of  arthritis  deformans. 


Fig.  458. — Luxatio  tVmoris  supracotyloidea  in 
veterata  with  a  perfectly  formed  new  acetab 
uluin  (pre]>aratiou  from  the  collection  ii 
the  surgical  clinic  at  Bonn — Kronleiu). 


Symptoms  and  Diagnosis  of  Uncomplicated  Traumatic  Dislocations. — - 
The  symptoms  of  traumatic  dislocations  are  partly  objective  and  partly 
subjective.  The  objective  symptoms  are  :  (1)  A  change  in  the  contour 
of  the  joint ;  (2)  a  change  in  the  relative  positions  of  the  articular  ends 
of  the  bones ;  (3)  a  change  in  the  axis  of  the  Hmb ;  (4)  a  lengthening 
or  shortening  of  the  dislocated  limb  (Figs.  459,  460).  The  change  in 
the  contour  of  the  joint  is  often  evident  to  an  experienced  eye  at  the 
first  glance.  The  patient  should  always  be  sufiiciently  undressed  to 
render  a  comparison  between  the  sound  and  damaged  side  possible ; 
one  can  then  note  the  normal  configuration  of  the  uninjured  joint, 
the  normal  position  of  the  bony  prominences,  the  relationship  of  the 


122.] 


DISLOCATIONS   OF  JOINTS. 


743 


folds  of  the  skin  and  soft  parts  on  the  healthy  and  the  abnormal 
depressions  and  elevations  on  the  diseased  side  resultin^^-  from  tlie 
changed  situation  of  the  head  of  the  dislocated  bone.  The  most 
important  symptom — viz.,  the  abnormal  position  of  the  head  of  the 
dislocated  bone — can  be  recognised  by  palpation  or  by  making  move- 
ments with  the  dislocated  limb.  The  altered  direction  in  which  the 
latter  points  is  usually  such  that  the  long  axis  of  the  luxated  bone 
does  not  strike  the  articular  cavity  of  the  other,  but  passes  outside  of 
it;  in  the  case  of  the  shoulder,  for  example,  the  long  axis  of  the 
humerus  passes  outside  of  the  glenoid  cavity  (Figs.  459,  460).  The 
dislocated  limb,  in  the  majority  of  instances,  is  shortened,  rarely 
lengthened,  and  assumes  a  position  which  is  perfectly  characteristic  in 
every  dislocation. 

The  subjective  symptoms  are  pain,  and  inability  to  perform  normal 
movements  with  the  injured  limb.  The  disturbances  of  function  usu- 
ally consist  of  a  loss  of  active  mo- 
tion, while  passive  movements  are 
possible  to  some  extent.  The  lat- 
ter are  often  very  easily  carried 
out  in  a  certain  direction,  while  in 
others  they  may  be  quite  impos- 
sible. 

From  what  we  have  just  said, 
it  follows  that  the  diagnosis  of  dis- 
locations, especially  soon  after  the 
accident,  is  usually  not  difficult.  If 
the  swelling  due  to  the  effusion  of 
blood  is  very  large,  it  can  be  re- 
duced in  size  by  gentle  massage, 
possibly  under  an  anaesthetic.  Dis- 
locations are  most  likely  to  be  con- 
fused with  fractures  of  the  articu- 
lar ends  of  the  bones.  The  latter 
may  be  suspected  if  the  dislocation, 
or,  rather,  the  deformity,  is  easily  reduced  by  slight  traction  applied  to 
the  injured  limb,  but  returns  again  immediately  when  extension  is  dis- 
continued. In  dislocations,  on  the  other  hand,  special  manoeuvres  are 
necessary  to  cause  a  disappearance  of  the  deformity,  and  when  reduc- 
tion has  once  taken  place  the  change  of  contour  does  not  again  recur 
spontaneously.  In  fractures,  abnormal  mobility  and  crepitus  are 
■usually  present,  while  in  dislocations  there  is  an  abnormal  fixation  of 
the  limb,  and  certain  movements  are  quite  impossible.     A  kind  of 


Fig. 


459. — Subcoracoid  dislocation  of  the  left 
shoulder. 


iU 


INJURIES  AND  DISEASES  OF  JOINTS. 


crepitus  is  also  sometimes  met  with  in  dislocations,  but  it  is  softer 
than  bone  crepitus,  and  is  due  to  blood  coagula  and  to  the  tearing 
of  the  ligaments  of  the  capsule  or  of  the  tendons. 

Complications  of  Dislocations. — The  most  important  complications  of 
dislocations  are  :  (1)  Extensive  injury  to  the  skin  and  subcutaneous  soft 
parts  over  the  joint ;  (2)  fracture  occurring  simultaneously  with  the  dis- 
location ;  (3)  rupture  of  large  vessels  and  nerves ; 
(4)  injury  to  internal  organs. 

Division  of  the  skin  and  subcutaneous  soft 
parts  with  exposure  of  the  head  of  the  dislo- 
cated bone  is  not  common ;  it  is  observed  most 
often  at  the  elbow,  in  the  fingers,  at  the  knee, 
and  at  the  ankle.  Such  compound  dislocations 
are  always  to  be  looked  upon  as  serious  injuries, 
especially  when  they  are  combined  at  the  same 
time  with  fracture.  The  sooner  a  compound 
dislocation  is  subjected  to  antiseptic  treatment 
the  better  will  be  the  prospect  of  preventing  in- 
fection and  a  serious  suppurative  arthritis  (see 
§  123,  Wounds  of  Joints). 

The  most  common  complication  of  a  dislo- 
cation is  a  fracture  occurring  at  the  same  time. 
The  fracture  may  either  involve  the  cortex,  a 
portion  of  bone  being  torn  off  at  the  point  of 
attachment  of  some  ligament  or  tendon,  or  the 
fulcrum,  or  the  dislocated  bone  itself,  or  the 
non-dislocated  parallel  bone,  such  as  the  ulna, 
which  may  be  broken  below  the  elbow  in  for- 
ward dislocations  of  the  head  of  the  radius.  The 
fractures  of  least  importance  are  those  of  the 
cortex  and  of  bony  prominences  like  the  tuber- 
osities of  the  humerus  or  the  malleoli.  Frac- 
tures of  the  rim  of  the  acetabulum  at  the  hip,  and  of  the  glenoid  cavity 
at  the  shoulder,  are,  on  the  other  hand,  more  serious,  since  they  increase 
the  difficulty  of  reduction  or  favour  a  recurrence  of  the  dislocation. 
If  a  fracture  occurs  in  a  dislocated  bone,  the  dislocation  usually  takes 
place  first  and  then  the  fracture. 

Rupture  of  large  vessels  or  nerves  is  very  rare,  and  is  sometimes 
the  result  of  unskilful  reduction  of  an  old  dislocation.  Stretching  and 
crushing  of  the  vessels  and  nerves  are,  however,  more  common.  Crush- 
ing of  the  vessels  occasionally  gives  rise  to  extensive  thrombosis  fol- 
lowed by  gangrene,  especially  if  the  dislocation  is  not  promptly  reduced^ 


Fig.  460. — Dislocation  of  the 
hip  backwards  (luxatio 
iliaca). 


§122.]  DISLOCATIONS  OF  JOINTS.  Y45 

Of  the  injuries  of  nerves,  those  of  the  circumflex,  with  paralysis  of  the 
deltoid  muscle,  are  the  most  frequent. 

Of  the  injuries  of  internal  organs,  I  should  mention  injury  of  the 
spinal  cord  in  dislocation  of  the  vertebrae,  of  the  bladder,  intestine, 
and  pelvic  organs  in  luxatio  femoris  centralis — i.  e.,  dislocation  of  the 
femur  inwards  through  the  acetabulum,  also  compression  of  the  tra- 
chea and  oesophagus  in  dislocation  of  the  sternal  end  of  the  clavicle, 
etc.  Prochaska  saw  a  case  in  which  the  head  of  the  humerus  pene- 
trated the  thorax  between  the  second  and  third  ribs. 

Prognosis  of  Traumatic  Dislocations.— As  regards  the  prognosis,  it  is 
important  for  us  to  consider  (1)  whether  we  have  to  deal  with  a  simple  or  a 
compound  dislocation,  (3)  whether  complications  are  present,  and,  if  so,  their 
nature,  and  (3)  the  region  of  the  body  and  the  particular  joint  where  the  dis- 
location has  occurred.  We  usually  expect  perfect  recovery  to  take  place 
in  the  case  of  simple  uncomplicated  dislocations  which  have  been  success- 
fully reduced.  Should  the  dislocation  not  be  reduced,  a  new  joint  or  ne- 
arthrosis is  formed,  as  we  saw  above,  in  the  abnormal  situation  occui^ied  by 
the  articular  end  of  the  dislocated  bone,  particularly  if  the  dislocation  were 
one  of  the  shoulder  or  hip.  Occasionally  a  dislocation  will  recur  from  even 
a  very  slight  amount  of  violence,  and  particularly  if  extensive  movements 
are  made  with  the  joint  at  too  early  a  period. 

We  soQietimes  meet  with  individuals  who  in  this  way  suffer  from  very 
frequent  recurrences  of  the  same  dislocation,  especially  that  of  the  shoulder, 
jaw,  or  the  hip,  and  there  are  people  who  have  dislocated  their  shoulder 
or  jaw  more  than  fifty  or  one  hundred  times.  These  "  habitual  dislocations," 
as  they  are  called,  have  many  different  causes,  but  they  are  usually  due  to  a 
lax  condition  of  the  capsule  and  its  accessory  ligaments,  which  have  become 
stretched  and  torn  to  such  an  extent  that  the  cavity  of  the  joint  is  enlarged, 
and  a  dislocation  can  take  place  without  the  occurrence  of  any  fresh  tear. 

Treatment  of  Traumatic  Dislocations. — The  treatment  of  recent  un- 
complicated dislocations  consists  in  bringing  the  displaced  articular  end 
of  the  bone  back  into  its  socket  by  special  methods  of  reposition, 
and  then  immobilising  the  joint  until  the  rent  in  the  capsule  has 
healed.  The  reposition  was  at  one  time  carried  out  in  a  very  forcible 
and  rough  way,  and  not  infrequently  with  the  aid  of  mechanical  con- 
trivances, pulleys,  etc. ;  so  that  sometimes  disastrous  consequences — 
such  as  severe  injuries  to  the  skin,  vessels,  nerves,  and  muscles,  or 
fractures — followed,  and  in  some  instances  even  entire  extremities  were 
torn  away.  At  present  we  have  in  general  anaesthesia  an  excellent 
means  of  rendering  the  reduction  of  dislocations  easy  and  painless.  An 
attempt  should  first  be  made  to  reduce  a  recent  dislocation  without  an 
anaesthetic,  and  if  this  is  found  to  be  impossible  chloroform  should  be 
administered,  but  with  great  caution,  because  a  collapse  resulting  in 
death  may  easily  take  place,  especially  in  habitual  drinkers,  who  are 


746  INJURIES  AND  DISEASES  OP  JOINTS. 

much  excited  bj  the  accident.  The  sooner  after  the  accident  reduction 
is  performed  the  more  easily  it  is  accomplished.  The  movements 
employed  for  reducing  a  dislocation  must  be  carried  out  according  to 
certain  rules,  which  vary  vrith  the  nature  of  the  case,  and  in  making 
them  one  should  always  take  into  consideration  the  shape  of  the  joint 
and  the  nature  and  location  of  the  rent  in  the  capsule.  Impediments 
to  the  reduction  of  recent  dislocations  are  furnished  by  active  contrac- 
tion of  the  muscles,  by  the  narrowness  or  unfavourable  location  of  the 
rent  in  the  capsule,  by  portions  of  capsule  which  still  remain  intact 
though  stretched  and  abnormally  situated,  and  by  interposition  of  por- 
tions of  the  capsule,  tendons,  muscles,  and  fragments  of  bone.  Active 
contraction  of  the  muscles  and  the  elastic  tension  of  the  soft  parts  are 
overcome  by  chloroform  anaesthesia.  It  is  evident  that  the  movements 
made  in  accomplishing  reduction  must  differ  very  greatly  according  to 
the  nature  of  the  case  and  the  site  of  the  dislocation  ;  that  sometimes 
rotation,  sometimes  flexion  or  extension,  and  sometimes  abduction  or 
adduction  must  be  performed ;  and  Kronlein  is  right  in  saying  that  it 
is  not  so  much  the  etiology  of  a  dislocation  as  it  is  its  anatomy  which 
determines  our  method  of  treatment.  By  means  of  the  movements  or 
manipulations  aimed  at  reduction  the  head  of  the  dislocated  bone  is 
brought  opposite  the  rent  in  the  capsule  or  the  socket,  and  then,  with 
a  snapping  souTid  or  perceptible  jolt,  caused  to  enter  the  cavity  of  the 
joint.  As  a  rule,  it  is  well  to  combine  with  the  above-mentioned 
manipulations  a  direct  pressure  upon  the  articular  end  of  the  dislocated 
bone.  For  the  methods  of  reducing  the  various  dislocations  of  the 
different  joints  I  must  refer  the  reader  to  the  Regional  Surgery.  The 
restoration  of  the  normal  contour  and  functions  of  the  joint  will  show 
at  once  that  the  reduction  of  the  dislocation  has  been  successful. 

The  after-treatment  consists  in  keeping  the  replaced  portions  of 
the  articulation  at  rest  by  means  of  light,  immobilising  dressings.  In 
dislocations  of  the  shoulder,  for  example,  it  will  suffice  if  the  arm  is 
held  firmly  fixed  by  a  mitella  (see  Fig.  181),  which  is  secured  in  posi- 
tion by  a  few  turns  of  a  bandage  around  the  arm  and  thorax.  In  dis- 
locations of  the  hip  the  patient  should  be  kept  in  bed,  a  spica  coxae 
(see  Fig.  169j  applied  about  the  joint,  and  the  limb  immobilised  by  a 
cloth  passed  around  the  leg  in  the  region  of  the  knee.  It  is  difficult 
to  keep  some  joints  reduced,  as  is  the  case  with  forward  dislocations  of 
the  head  of  the  radius  and  dislocations  of  the  acromio-clavicular  and 
sterno-clavicular  articulations.  In  such  instances  an  attempt  must  be 
made  to  hold  the  bone  in  place  by  dressings  which  exert  pressure,  by 
pads,  or,  when  necessary,  by  the  use  of  nails  or  bone  sutures.  After 
the  lapse  of  some  eight,  ten,  or  fourteen  days — depending  upon  the 


§122.]  DISLOCATIONS   OF  JOINTS.  74Y 

nature  of  the  case — passive  motion  of  the  dislocated  joint  should  be 
begun  in  order  to  prevent  subsequent  stiffness.  Extreme  movements 
of  the  joint  should,  however,  not  be  attempted  during  the  next  few 
weeks,  because  the  healing  of  the  lacerations  in  the  capsule  and  liga- 
ments may  be  interfered  with,  or  the  cicatrices  of  these  structures 
may  be  so  stretched  that  the  dislocation  easily  recurs,  or  even  be- 
comes habitual. 

The  treatment  of  habitual  dislocations,  as  a  rule,  is  very  difficult, 
particularly  in  marked  cases.  Long-continued  rest  of  the  joint  in 
one  position  is  usually  unsuccessful,  because  the  injured  jDcrson  has 
not  the  required  patience.  Yery  often  nothing  remains  but  to  restrict 
the  movements  of  the  joint  by  means  of  a  suitable  bandage.  In  bad 
cases  it  may  be  well  to  expose  the  joint  under  antiseptic  precautions, 
and  either  suture  the  rent  in  the  capsule  or  resect  the  head  of  the 
bone.  Genzmer  successfully  treated  two  cases  of  habitual  dislocation — 
one  of  the  shoulder  and  the  other  of  the  jaw — by  the  subcutaneous 
injection  of  pure  tincture  of  iodine  (0.5  to  0.75  cubic  centimetres  tinct. 
iodi.  injected  by  a  hypodermic  syringe  at  intervals  of  three  to  four 
days,  until  six  to  eight  injections  have  been  made).  Subcutaneous 
injections  of  absolute  alcohol  might  also  be  tried. 

In  fresh  dislocations  which  are  irreducible  an  aseptic  arthrotomy 
should  be  performed — i.  e.,  the  site  of  the  dislocation  should  be 
exposed  by  an  incision  and  the  head  of  the  bone  then  brought  back 
into  place,  or  resected  if  reduction  is  otherwise  impossible.  But  recent 
simple  dislocations  seldom  require  operative  interference,  since  reduc- 
tion can  generally  be  accomplished,  especially  if  chloroform  is  used. 

One  should  first  try  to  reduce  even  old  dislocations  by  the  usual 
method,  though  they  may  have  existed  for  weeks,  months,  or  years ; 
luxations  of  the  shoulder  and  also  of  the  hip  have  thus  been  success- 
fully brought  back  into  place  two  years  after  the  accident.  The  possi- 
bility of  reduction  in  these  cases  depends  mainly  upon  the  extent  of 
the  injuries, which  the  soft  parts  have  suffered,  upon  the  greater  or  less 
degree  of  fixation  of  the  dislocated  articular  end  of  the  bone  in  its  new 
position,  and,  finally,  upon  whether  the  joint  cavity  is  much  diminished 
in  size  or  quite  obliterated.  After  thoroughly  ansesthetising  the  pa- 
tient with  chloroform,  the  same  manipulations  are  employed  for  the 
reduction  of  old  dislocations  as  for  those  which  are  recent,  the  articular 
end  of  the  bone  being  first  freed  by  rotatory  movements.  The  manipu- 
lations aimed  at  reduction  should  be  made  with  great  care  so  as  not  to 
injure  the  bones  or  soft  parts.  The  mechanical  contrivances  once  so 
extensively  used,  such  as  pulleys,  windlasses,  etc.,  have  become  obsolete 
and  have  only  a  historic  interest.     Even  though  the  reduction  is  sue- 


748  INJURIES   AND   DISEASES  OF  JOINTS. 

cessfully  accomplished  a  good  result  is  not  always  assured,  as  the  joint 
often  remains  stiff  in  spite  of  massage,  electricity,  and  active  and  pas- 
sive motion.  If  reduction  is  impossible,  the  dislocation  should  be 
exposed  by  an  incision — i.  e.,  arthrotomy  should  be  performed  and  the 
head  of  the  bone  returned  to  its  normal  position,  especially  in  those 
cases  in  which  the  limb  has  become  useless  owing  to  malposition,  or  in 
which  the  dislocated  articular  end  of  the  bone  causes  pain  and  paralysis 
by  pressing  upon  the  nerves.  In  such  instances  resection  of  the  articu- 
lar end  of  the  bone  will  often  be  necessary  as  a  preliminary  step  in  per- 
forming reduction.  At  the  hip  the  position  of  the  limb  is  sometimes 
best  corrected  by  osteoclasis  or  subtrochanteric  osteotomy.  In  other 
cases  of  old  irreducible  dislocations  one  may  try  to  make  as  good  a 
nearthrosis  as  possible  by  means  of  massage,  passive  motion,  electricity, 
and  warm  baths. 

Dislocations  in  which  the  joint  is  opened  are  treated  by  the  same 
rules  that  apply  to  wounds  of  joints  (see  page  723).  Under  these  cir- 
cumstances, also,  reduction  should  be  performed  as  promptly  as  possible, 
taking  every  antiseptic  precaution  and  providing  for  drainage  of  the 
joint.  According  to  Drewitz,  reduction  without  resection  of  the  head 
of  the  hone  gave,  even  in  preantiseptic  times,  movable  joints  in  forty 
per  cent,  of  the  cases.  If  difficulties  are  met  with  in  performing 
reduction  the  knife  should  be  made  use  of,  and  when  reduction  has 
been  accomplished  the  joint  should  be  carefully  drained  and  immo- 
bilised. If  the  soft  parts  have  been  very  much  injured  permanent 
irrigation  should  be  employed.  Resection  of  the  head  of  the  dislocated 
bone  is  indicated  in  cases  complicated  by  comminuted  f]-actures,  exten- 
sive injury  to  the  soft  parts,  suppuration  within  the  joint,  or  where 
reduction  is  impossible  by  other  means.  If  sepsis  has  already  made  its 
appearance  prompt  amputation  or  disarticulation  may  be  necessarv. 

If  both  dislocation  and  fracture  occur  together,  it  should  be  our 
first  aim  to  reduce  the  dislocation  when  this  is  possible,  using,  for 
example,  direct  pressure  upon  the  articular  fragment  in  the  case  of 
dislocation  and  fracture  of  the  humerus  at  the  shoulder  joint.  In 
other  instances  reduction  of  the  dislocation  may  be  impossible,  and  the 
fracture  must  first  be  allowed  to  heal  before  the  dislocation  is  attended 
to.  In  suitable  cases  operative  measures  must  be  undertaken — i.  e.,  the 
seat  of  injury  should  be  exposed,  and  whatever  measures  the  condition 
calls  for  adopted.  The  prognosis  of  all  dislocations  which  are  compli- 
cated by  fracture  should  be  looked  upon  as  doubtful  as  regards  restora- 
tion of  the  normal  mobility  of  the  joint. 

The  other  complications,  such  as  injuries  to  vessels  and  nerves,  are 
to  be  treated  in  the  usual  way  (see  §  88). 


§122.]  DISLOCATIONS   OF  JOINTS.  7^9 

Dislocation  of  the  semilunar  cartilages  of  the  knee  rarely  occurs  inde- 
pendently of  other  changes  in  the  joint.  Habitual  dislocation  of  these  car- 
tilages has  been  observed,  the  most  common  variety  being  a  displacement  of 
the  inner  cartilage  forwards,  due  to  forced  flexion  of  tlje  knee-joint  combined 
with  outward  rotation  of  the  foot,  or,  rather,  leg.  The  displaced  cartilage  can 
be  felt  on  the  anterior  border  of  the  joint,  the  knee  is  somewhat  flexed,  and 
complete  extension  is  impossible. 

For  a  description  of  dislocations  of  tendons  and  nerves  see  pages  525,  526. 

II.  Pathological  or  Spontaneous  Dislocations  are  observed  in  the 
course  of  diseases  of  joints  either  as  a  result  of  an  abnormal  stretch- 
ing or  lax  condition  of  the  capsule  and  ligaments,  or  of  changes  in  the 
articular  ends  of  the  bone  such  as  those  caused  by  arthritis  deformans 
or  caries.  Under  such  circumstances  either  an  incomplete  or  a  com- 
plete dislocation  takes  place,  coming  on  gradually  and  brought  about 
by  the  weight  of  the  limb,  or  suddenly  from  some  slight  traumatism, 
muscular  action,  etc. 

We  distinguish :  1.  Distention  Dislocations,  due  to  a  stretching  or 
lax  condition  of  the  capsule  and  ligaments  of  the  joint  caused  by  a 
serous,  sero-fibrinous,  or  more  rarely  suppurative  effusion.  Complete 
and  incomplete  dislocations  of  this  kind  are  especially  common  in  the 
course  of  metastatic  inflammations  of  joints  with  large  collections  of 
fluid,  such  as  occur  in  typhoid  fever,  small-pox,  measles,  scarlet  fever, 
diphtheria,  puerperal  fever,  and  pyaemia.  The  capsule  and  ligaments 
of  a  joint — the  shoulder,  for  example — may  also  become  stretched  in 
cases  of  muscular  atrophy  and  paralysis.  Under  these  conditions  the 
muscles  are  not  capable  of  supporting  the  extremity,  and  thus  allow 
disjDlacements  of  the  joint  surfaces  to  take  place  either  gradually  or 
suddenly.  The  voluntary  dislocations  mentioned  on  page  741  are  like- 
wise looked  upon  by  some  authors  as  distention  dislocations. 

Quite  recently  A^erneuil  has  called  attention  to  dislocations  which  occur 
during  acute  articular  rheumatism  and  run  a  course  exactly  like  that  of 
traumatic  dislocations.  In  all  cases  the  luxations  took  place  suddenly  and 
spontaneously,  and  could  be  reduced  very  easily  under  an  anassthetic.  In 
other  cases  when  the  dislocation  could  not  be  i^educed,  resection — of  the  hip, 
for  example — had  to  be  performed.  Yerneuil  thinks  that  these  dislocations 
are  caused  by  muscular  action  and  a  lax  condition  of  the  ligaments. 

2.  Destruction  Dislocations. — The  most  common  form  of  patho- 
logical dislocation  is  due  to  a  carious  destruction  of  the  joint  surfaces 
combined  with  corresponding  changes  in  the  capsule  and  ligaments. 
In  this  category  belong  the  so-called  "  wandering  of  the  acetabulum  " 
in  coxitis  (page  701,  Fig.  tl-ll)  and  the  spondylolisthesis — i.  e.,  the 
slipping  down  of  the  last  lumbar  vertebra  into  the  pelvis  in  cases  of 


750 


INJURIES  AND  DISEASES  OP  JOINTS. 


Fig.  461. — Congenital  dislocation  of  the  left  hip  in  a 
six-months'-old  girl :  a,  remains  of  tlie  capsule 
■which  has  been  dissected  away ;  6,  undeveloped 
acetabulum. 


tubercular  destruction  of  the  corresponding  intervertebral  ligaments 
(see  §  114). 

3.  Deformity  Dislocations,  which  are  the  result  of  changes  in  the 
shape  of  the  bony  pa'rts  of  the  joint  due  to  an  atrophy  of  l)one  without 

suppuration  and  without  the 
production  of  granulations. 
They  most  commonly  occur 
in  connection  with  arthritis 
deformans  (see  page  Q^Q^ 
Fig.  447). 

For  the  course,  diagnosis, 
and  treatment  of  pathological 
dislocations  see  ^  113,  ^j  114, 
§  119  (Inflammations and  De- 
formities of  Joints),  and  the 
above  description  of  traumat- 
ic dislocations. 

III.  Congenital  Disloca- 
tions. —  Congenital  disloca- 
tions are  mainly  the  result  of 
anomalous  or  arrested  foetal  development.  They  are  most  common  at 
the  hip  (Fig.  461),  being  very  rarely  found  in  the  rest  of  the  joints, 
and  are  occasionally  combined  with  other  anomalies  of  development, 
such  as  club-foot,  spina  bifida,  and  exstrophy  of  the  bladder.  These 
congenital  dislocations,  which  take  place  in  utero,  should  not  be  con- 
fused with  the  traumatic  ones  which  take  place  during  delivery  and 
are  due  to  extraction  of  the  child.  This  latter  form  of  dislocation  is, 
however,  extremely  rare,  fractures,  especially  at  the  epiphysis,  on 
account  of  the  latter's  slight  power  of  resistance,  being  much  more 
common.  But  it  is  probable  that  in  some  cases  extraction  of  the  foetus 
causes  a  stretching  of  the  capsule,  thus  furnishing  a  predisposition  to 
dislocation  which  subsequently  becomes  more  marked  as  the  joint  is 
used  in  walking. 

Investigations  relating  to  the  Pathology  and  Etiology  of  Congenital 
Dislocations. — These  investigations  have  to  do  ahnost  exclusively  with  con- 
genital dislocations  of  the  hip.  I  have  had  opportunities  of  examining  dis- 
locations of  this  kind  in  female  children  at  the  autopsy  (Fig.  4611.  I  have 
usually  found  the  acetabulum  abnormally  fiat  and  the  head  of  tlie  bone 
lying  at  its  upper  and  posterior  border.  The  neck  of  the  femur  usually 
forms  an  obtuse  angle  with  the  shaft.  The  capsule  of  the  joint  is  generally 
normally  formed.  In  one  case  I  found  in  a  female  child  six  months  of  age 
that  the  ligamentum  teres  was  so  much  thickened  and  lengthened  that  the 
head  of  the  femur,  which  was  situated  near  the  anterior  superior  spine,  did 


132.] 


DISLOCATIONS   OF  JOINTS. 


rsi 


not  have  sufficient  room  in  the  shallow  acetabulum.     The  pelvis  was,  more- 
over, asymmetrical. 

Congenital  dislocation  of  the  hip  is  usually  one-sided ;  out  of  198  cases, 
Hoffa  found  that  134  were  one-sided.  At  the  outset  the  head  of  the  femur 
is  in  the  vicinity  of  the  upper  and  posterior  edge  of  the  acetabulum,  and  is 
later  pushed  upward  and  backwards  on  to  the  ilium.  Lordosis  of  the  verte- 
bral column  is  present,  especially  in  bilateral  dislocations,  and  the  patients 
have  a  very  characteristic  gait,  like  that  of  a  duck. 

The  main  cause  of  congenital  dislocation  of  the  hip  is  probably  to  be 
found  in  an  imperfect  development  of  the  acetabulum  or  the  cotyloid  liga- 
ment, and  its  occurrence  is  favoured  by  extreme  flexion  and  adduction  of 
the  thighs  of  the  foetus  (Fig.  -462,  Dupuytren,  Eoser).  A  very  small  uterus, 
which  exerts  abnormal  pressure  upon  the  foetus,  thus  causing  the  latter  to 
assume  a  cramped  position,  may  possibly  have  a  deleterious  influence  upon 
the  development  of  the  hip-joint.  The  obtuse  angle  which  the  neck  of  the 
femur  makes  with  the  shaft  (Fig.  461)  should  also  be  noted,  as  this  is  prob- 
ably not  always  a  secondary  condition,  but  one  which  may  sometimes 
develop  primarily  from  the  above-mentioned  cramped 
position  of  the  foetus  brought  about  by  a  uterus  which  is 
deficient  in  size.  Owing  to  the  obtuse  angle  which  the 
neck  of  the  femur  forms  with  the  shaft  (Fig.  461),  the 
head,  as  it  were,  grows  past  the  acetabulum  instead  of 
into  it.  Other  cases  of  congenital  dislocation  are  probably 
the  result  of  an  abnormally  long  and  thick  ligamentum 
teres,  which,  as  in  the  case  I  examined,  does  not  give  the 
head  sufficient  room  in  the  acetabulum.  In  older  chil- 
dren the  ligamentum  teres  is  usually  absent.  In  conse- 
quence of  the  abnormal  position  of  the  head  of  the  bone 
the  muscles  are  mostly  shortened,  and  the  direction  of 
their  action  is  altered.  Another  important  fact,  from  an 
etiological  point  of  view,  is  that  congenital  dislocations  of 
the  hip  are  much  more  common  in  females  than  in  males, 
87.6  per  cent,  of  all  cases  occurring  in  the  former  sex. 

From  careful  examinations  which  I  have  made  of 
the  foetal  pelvis,  I  believe  that  this  latter  fact  can  be  ex- 
plained by  the  comparatively  vertical  position  of  the  ilium 
in  females,  which,  in  conjunction  with  the  abnormal  angle 
formed  by  the  neck  of  the  femur  with  the  shaft,  readily 
allows  the  head  to  leave  the  shallow  acetabulum  and  glide 
up  on  to  the  ilium. 

It  follows  from  what  has  been  said  that  the  congenital  dislocations  of 
the  hip  are  undoubtedly  to  be  ascribed  to  anomalies  in  the  development  of 
the  foetus  due  to  various  causes. 

The  rare  cases  of  congenital  dislocations  of  other  joints  of  the  body 
are  probably  also  due  to  anomalies  of  foetal  development.  Congenital 
subcoracoid.  subacromial,  and  infraspinous  dislocations  of  the  shoulder 
have  been  reported,  as  well  as  congenital  dislocations  of  the  elbow, 
wrist,  knee,  and  ankle.     At  the  elbow,  congenital  dislocation  of  the 


Fig.  462.— The  man- 
ner in  which  a 
congenital  dislo- 
cation of  the  hip 
is  produced :  the 
leg  of  the  foetus  is 
forced  to  assume 
an  abnormally 
adducted  position 
by  a  uterus  which 
is  too  small  ( W. 
Koserj. 


752 


INJURIES  AND  DISEASES  OF  JOINTS. 


head  of  the  radius — backwards,  outwards,  forwards,  or  inwards— is  the 
most  coimnou. 

The  symptoms,  diagnosis,  and  treatment  of  congenital  dislocations 
of  the  diierent  joints  are  taken  up  at  length  in  the  Regional  Surgery, 
and  I  will  only  briefly  state  here  that  the  prognosis  is  usually  unfayour- 
ahle.  Still,  the  treatment  of  congenital  dislocations  of  the  hip  has 
recently  made  marked  progress,  owing  to  the  labours  of  Hoffa,  Lorenz, 
and  Mikulicz.     (For  further  particulars  see  Regional  Surgery.)     With 

the  aid  of  the  X-rays  it  is  possible 
to  determine  the  results  of  the  dif- 
ferent methods  of  treatment. 

§  123.  Wounds  of  Joints. — 
"Wounds  of  Joints  consist  of  punc- 
tured, incised, and  contused  wounds, 
and  wounds  which  are  comphcated 
with  fracture,  inchiding  gunshot 
wounds  (see  §  124).  Any  wound 
which  opens  a  joint — a  so-called 
penetrating  wound — eyen  though 
extremely  small,  should  be  looked 
upon  as  a  yery  serious  injury,  since 
it  may  more  or  less  completely  de- 
stroy the  function  of  the  joint,  and 
eyen  imperil  the  life  of  the  patient. 
The  escape  of  synovial  fluid  is  a 
symptom  which  indicates  beyond 
a  doubt  that  the  joint  has  been 
opened.  The  prognosis  of  pene- 
trating wounds  of  joints  is,  how- 
ever, much  more  favourable  than 
it  was  before  the  introduction  of 
the  antiseptic  method  of  treating 
wounds,  and  we  now  have  no  fear 
of  opening  a  joint  aseptically  with 
the  knife  or  trocar.  But  the  conditions  are  entirely  different  in  the  case 
of  accidental  wounds  made  with  an  unsterilised  instrument,  or  of  gun- 
shot wounds  into  which  dirty  pieces  of  clothing  have  pei-haps  entered. 
Under  such  circumstances  germs  of  infection  can  readily  make  their 
way  into  the  joint,  and  with  great  rapidity  cause  violent  inflammation. 
The  course  of  a  penetrating  wound  of  a  joint  depends  very  largely 
upon  whether  or  not  germs  of  infection  have  gained  access  to  the  joint 
at  the  time  of  the  accident,  or  afterwards. 


Fig.  463. — Double  congenital  dislocation  of 
the  iiip. 


§  123.]  WOUNDS   OF   JOINTS.  753 

We  shall  first  discuss  the  cases  in  which  everything  is  most  favour- 
able— i.  e.,  in  which  no  infection  of  the  wound,  a  punctured  one,  for 
example,  has  taken  place.  The  course  of  such  a  wound  will  then  be 
as  follows :  The  synovia  makes  its  appearance  at  the  time  of  the  acci- 
dent, but  soon  ceases  to  flow  out,  and  the  wound  becomes  agglutinated 
and  heals  up  without  causing  any  inflammation  or  disturbance  of  func- 
tion in  the  joint.  In  other  cases  a  mild  inflammation  occurs,  taking 
the  form  of  a  serous  or  sero-fibrinous  synovitis. 

The  course  of  an  infected  wound  of  a  joint  is  quite  different.  In- 
fection may  take  place  at  the  time  of  the  accident  or  later,  and  is 
then  due  to  improper  treatment  or  dirty  probes,  or  to  the  fact  that 
the  patient  pays  no  attention  to  the  wound,  and  walks  about,  thus,  by 
his  movement  of  the  parts,  permitting  air  and  infectious  germs  to 
have  free  access  to  the  joint.  In  some  cases  the  wound  has  already 
united,  and  then  on  the  third  to  the  fifth  day  manifestations  of  inflam- 
mation suddenly  make  their  appearance,  and  rapidly  increase  in  sever- 
ity. The  joint  is  swollen,  tense,  and  very  painful,  the  skin  is  red  and 
feels  hot,  and  there  is  high  fever.  If  the  agglutinated  borders  of  the 
wound  are  separated  by  a  probe,  or  if  the  sutures  are  removed,  pus 
immediately  makes  its  appearance.  Other  cases,  especially  those  in 
which  there  is  a  large  effusion  of  blood,  run  a  more  acute  course,  and 
the  local  and  general  symptoms  of  suppuration  in  the  joint  come  on 
within  twenty-four  hours  after  the  injury.  These  are  the  most  un- 
favourable ones,  and  unless  the  infected  contents  are  promptly  removed 
by  freely  opening  uj)  the  joint,  followed  by  drainage  and  antiseptic  irri- 
gation, or,  if  necessary,  by  resection,  acute  gangrene  of  the  joint  may 
rapidly  follow,  with,  perhaps,  general  sepsis. 

In  another  group  of  cases  the  course  is  more  subacute,  and  though 
the  exudate  within  the  joint  is  very  large  it  is  not  noticeably  suppu- 
rative in  character,  but  looks  like  cloudy  synovia  mixed  with  flakes 
containing  pus-cells  fsee  §  113). 

The  final  outcome  of  an  infected  wound  of  a  joint  varies,  though 
if  it  receives  antiseptic  treatment  early  enough  recovery  is  assured. 
In  some  cases,  after  a  longer  or  shorter  time,  the  suppurative  inflam- 
mation gradually  gets  well  spontaneously  without  any  particular  anti- 
septic treatment,  but  in  others  which  are  not  properly  attended  to  the 
suppuration  becomes  progressive,  breaks  through  the  capsule  of  the 
joint,  and  gives  rise  to  suppuration  in  the  neighbourhood,  while  the 
inflammation  in  the  joint  itself  apparently  diminishes  in  intensity. 
Such  suppurative  processes  not  infrequently  run  a  very  tedious  course, 
gradually  going  on  to  pysemia,  to  which  or  to  extreme  exhaustion  the 
patient  succumbs.  The  worst  cases  are  those  in  which  death  occurs 
51 


754  INJURIES  AND  DISEASES  OF  JOINTS. 

from  acute  septicaemia  within  a  few  days.  These  septic  or  gangrenous 
inflammations  of  joints  may  be  caused  by  a  very  shght  injury,  such  as 
puncture  of  the  joint  with  a  sewing  needle,  and  they  may  run  such  a 
rapid  course  that  even  on  the  fourth  or  tifth  day  death  from  septi- 
caemia cannot  be  prevented  even  by  amputation  or  disarticulation.  AVe 
have  ah-eady  described  the  course  and  outcome  of  the  different  varie- 
ties of  acute  inflammations  of  joints  in  the  chapters  devoted  to  Joint 
Inflammations. 

The  Repair  of  Wounds  in  Cartilage. — Gies  has  made  experiments  on 
young-  dogs  with  reference  to  the  repair  of  wounds  made  in  cartilage  and  has 
come  to  the  conclusion  that  clean  aseptic  wounds  in  this  tissue  never  heal, 
but  remain  permanently  unchanged,  while  wounds  which  are  made  in  the 
presence  of  micro-organisms  heal  up  so  completely  as  not  to  leave  any  or 
scarcely  any  traces  behind  them. 

The  escape  of  synovial  fluid  in  all  recent  cases  which  come  under 
observation  immediately  after  the  recejDtion  of  the  injury  has,  as  we 
remarked  before,  a  very  important  bearing  upon  the  diagnosis  of  pene- 
trating wounds  of  a  joint.  In  some  instances  in  which  the  joint  is 
laid  wide  open  the  exposed  articular  cartilages  may  be  recognised  at 
the  first  glance.  But  not  infrequently  the  puncture  or  other  wound  is 
already  closed,  so  that  it  is  doubtful  whether  the  joint  has  been  opened 
or  not,  and  under  these  circumstances  we  must  quietly  wait  for  fur- 
ther developments.  A  warning  should  be  given  here  against  probing 
wounds  too  freely  in  the  neighbourhood  of  a  joint. 

Treatment  of  Wounds  of  Joints. — Every  wound  of  a  joint,  even  the 
most  trivial,  should  be  treated  with  the  greatest  care.  We  shall  not 
discuss  the  treatment  of  gunshot  wounds  of  joints,  as  they  will  be 
taken  up  later  in  §  121:. 

Absolutely  fresh  cases  without  much  effusion  into  the  joint,  and 
without  apparent  infection,  are  treated  by  disinfection  of  the  wound 
and  its  neighbourhood.  I  do  not,  as  a  rule,  suture  such  wounds,  but 
merely  dust  them  with  iodoform,  cover  them  with  iodoform  or  Ijichlo- 
ride  gauze  which  has  been  moistened  in  a  l-to-1,000  solution  of  bichlo- 
ride of  mercury,  and  over  this  place  sterilised  cotton.  Large  wounds 
should  Ije  packed  with  iodoform  or  sterilised  gauze.  The  antiseptic 
occlusive  dressing  should  be  as  large  as  possil)le,  and  the  joint  must  be 
carefully  immol:)ilised  by  splints.  The  time  for  changing  the  dressings 
depends  upon  the  subsequent  course  of  the  injury,  and  very  often  asep- 
tic healing  takes  place  without  changing  the  dressing  at  all.  But  should 
fever  make  its  appearance  and  the  patient  complain  of  pain,  the  dress- 
ing must  be  changed  immediately.  If,  upon  taking  off  the  dressing,  it 
is  evident  that  the  joint  has  become  infected  and  that  an  acute  suppu- 


§124]  GUNSHOT  INJURIES.  755 

rative  inflammation  has  developed,  thorough  disinfection  and  drainage 
of  the  joint  must  be  begun  at  once.  The  joint  should  be  freely  opened, 
all  pockets  within  it  disinfected  with  a  l-to-1,000  bichloride  solution, 
and  any  blood-coagula  that  may  be  present  carefully  removed.  Short 
and  thick  drainage  tubes — preferably  of  glass — must  be  inserted  in 
those  places  where  they  can  most  effectually  help  to  carry  off  the  dis- 
charges. In  suitable  cases  the  wound  is  packed  with  iodoform  gauze 
or  sterilised  mull,  and  it  is  also  of  the  greatest  importance  to  secure 
immobilisation  of  the  joint.  The  dressings  must  be  changed  often, 
depending  upon  the  height  of  the  temperature.  Not  infrequently  one 
has  the  pleasure  of  seeing  that  this  treatment  is  followed  by  excellent 
results,  that  the  inflammation  of  the  joint  is  averted,  and  that,  even  in 
cases  where  one  could  hardly  have  expected  it,  perfect  mobility  of  the 
joint  is  regained  despite  the  fact  that  suppurative  arthritis  has  occurred. 

If,  in  spite  of  disinfection  and  drainage  of  the  joint,  severe  consti- 
tutional symptoms  make  their  appearance,  or  if  the  suppuration  that  is 
present  is  very  extensive,  so  that  drainage  of  the  joint  presents  great 
difficulties,  resection  is  then  indicated ;  or,  if  general  systemic  infec- 
tion threatens,  the  focus  of  infection  must  be  removed  by  am23utation 
or  disarticulation. 

If  the  patient  comes  under  treatment  after  suppuration  has  already 
begun,  antiseptic  incision  and  drainage,  or  packing  of  the  joint  with  or 
without  resection,  or  even  amputation  are  indicated,  depending  upon 
the  amount  of  suppuration  and  the  length  of  time  the  disease  has  lasted. 
In  opening  up  infected  cases  of  this  kind  one  should  not  be  afraid  of 
making  too  many  incisions  into  the  different  parts  of  the  joint.  Con- 
tinuous antiseptic  irrigation  will  often  be  found  a  most  excellent  aid  in 
the  subsequent  treatment  (see  page  181).  Any  complications  that  may 
be  encountered — fractures,  for  instance — are  to  be  treated  in  the  usual 
way.     (See  page  622,  Treatment  of  Compound  Fractures.) 


Appendix. 

Gunshot  wounds.  Military  practice. 
§  121:.  Gunshot  Injuries. — In  connection  with  wounds  of  joints,  we 
shall  give  a  short  description  of  the  gunshot  wounds  which  have  already 
been  referred  to  several  times  in  speaking  of  injuries  to  the  different 
tissues.  We  must,  of  course,  confine  ourselves  here  merely  to  a  brief 
sketch,  and  whoever  cares  to  become  better  acquainted  with  this  ex- 
tremely interesting  subject  should  read  the  excellent  works  of  Stro- 
meyer,  Pirogoff,  Langenbeck,  Billroth,  Esmarch,  etc.  The  literature 
of  gunshot  wounds  and  military  surgery  is  very  extensive.     Of  the 


756  INJURIES  AND   DISEASES  OF  JOINTS. 

older  books,  I  should  speak  especially  of  the  memoirs  of  Larrey,  the 
famous  army  surgeon  of  Xapoleon  I,  and,  among  English  works,  of 
The  Principles  of  Military  Surgery,  l)y  John  Hennen. 

Gunshot  wounds  are  essentially  contused  and  lacerated  wounds,  and 
are  most  commonly  caused  by  hand  firearms.  The  projectiles  of  the 
latter  (shot-guns,  revolvers,  pistols)  are  generally  cylindrical  or  shaped 
Hke  an  acorn,  and  are  usually  made  of  lead.  The  bullets  used  in  mod- 
ern weapons — i.  e.,  those  of  small  calibre  (eight  millimetres),  at  present 
employed  by  the  European  armies — are  long  and  cylindrical,  and  con- 
sist of  a  lead  core  encased  in  steel.  Owing  to  this  steel  covering  the 
bullets  are  very  resistant  and  retain  their  shape  when  they  strike  a 
bone  or  pass  through  the  body.  The  penetrating  power  of  these  bul- 
lets is,  as  we  shall  see,  very  extraordinary.  The  lead  bullets  become 
so  soft  from  friction  as  they  pass  through  the  barrel  of  the  gun  and 
the  air  that  they  change  their  shape  very  materially  and  break  up  into 
single  pieces,  so  that  an  explosive  eiiect  results.  "When  they  strike 
bone,  for  example,  they  become  flattened  out,  split,  shattered,  or  broken 
np  into  irregular,  pointed  fragments  of  lead.  In  the  case  of  shots  fired 
from  a  short  distance  the  bullet  is  heated  to  a  very  high  tem|)erature, 
and,  as  we  shall  see,  it  is  under  these  circumstances  that  its  explosive 
action  is  most  likely  to  take  place. 

Bullets  cause  the  following  injuries:  1.  The  mildest  form  of  gun- 
shot injury  is  contusion  of  the  soft  parts,  with  extravasation  but  with- 
out a  wound.  These  contusions  of  the  skin  or  soft  parts  are  usually 
made  l)v  spent  balls  coming  from  a  great  distance.  In  rare  cases  sub- 
cutaneous fractures  are  also  produced  in  this  manner.  Occasionally 
the  contused,  undivided  skin  is  pressed  inwards  like  a  pouch,  thus 
causing,  when  the  bullet  strikes  upon  the  abdomen,  contusion  and 
laceration  of  internal  organs,  of  which  the  liver  may  be  one.  More- 
over, bullets  which  have  a  great  velocity  can  be  so  checked  by  striking 
a  watch,  purse,  pocketbook,  pieces  of  leather  on  the  uniform,  etc.,  that 
only  a  contusion  \vithout  any  wound  results.  Bullets  of  small  calibre 
with  a  covering  of  nickel  or  steel  cannot  be  stopped  in  this  way,  as 
they  have  an  extraordinary  penetrating  jDower. 

2.  Furrowed  ^vounds  are  caused  by  bullets  which  graze  the  surface 
of  the  body  and  carry  with  them  a  portion  of  the  skin,  so  that  a  more 
or  less  deep  furrow  is  formed. 

3.  The  most  common  gunshot  injuries  are  tuhidar  icotinds — i.  e., 
the  ball  passes  through  the  skin  and  enters  the  soft  parts,  where  it 
either  remains  lodged  (so-called  blind  shot  canal)  or  comes  out  again 
at  another  part  of  the  body  ("  seton  shot ''),  thus  making  an  opening 
where  it  entered  and  one  where  it  emerojed.     The  differentiation  of 


§  124.]  GUNSHOT  INJUEIES.  Y57 

the  points  of  entrance  and  exit  is  of  importance  notably  from  a  medico- 
legal point  of  view.  The  point  of  entrance  is*  usually  more  or  less  in- 
dented, depending  upon  the  size  of  the  bullet,  and  is  coloured  bluish- 
black,  while  the  exit  opening  is  generally  smaller  and  looks  more 
like  a  tear.  These  points  of  difference  do  not,  however,  always  hold 
good,  as  the  opening  of  exit  is  sometimes  larger  than  that  of  entrance, 
particularly  when  a  bone  is  splintered  or  when  the  ball  changes  its 
shape  or  becomes  broken  into  pieces.  Occasionally  several  points  of 
exit  are  found,  especially  if  tbe  bullet  has  been  fired  at  short  range, 
as  this  produces  an  effect  like  an  explosion,  shattering  the  bone  into 
separate  splinters,  which  perforate  the  skin.  The  burning  of  the  integu- 
ment is  often  very  extensive  when  the  revolver  or  pistol  has  been  dis- 
charged close  to  the  body,  as  in  attempts  at  suicide,  and  then,  owino-  to 
the  healing. into  the  tissues  of  small  particles  of  powder,  the  skin  often 
remains  of  a  greyish-black  colour  for  the  rest  of  life.  The  same  is  true 
of  small  shot,  which,  when  fired  from  near  at  hand,  can  also  cause  very 
extensive  destruction  of  the  region  where  they  strike,  and  particularly 
severe  shock,  giving  rise  to  such  marked  symptoms  of  collapse  that  the 
patient  may  die  soon  after  the  injury.  Quite  recently  I  saw  a  bad  case 
of  collapse  occasioned  in  this  way,  in  a  hunter  who  was  struck  by  fifty- 
two  pieces  of  shot ;  but  in  spite  of  having  sustained  wounds  of  his 
lungs,  pericardium,  and  intestine,  the  patient  recovered. 

The  direction  of  the  track  of  the  bullet  is  sometimes  very  peculiar, 
and  instances  are  recorded  where  it  encircled  the  thorax  close  to  the 
ril)s  without  injuring  the  pleura  or  the  lungs.  The  entrance  into  a 
gunshot  wound  of  unclean  foreign  bodies,  such  as  bits  of  cloth,  leather, 
or  linen  from  the  clothing,  has  a  very  important  bearing  upon  the  sub- 
sequent course  of  the  injury,  as  substances  like  these  are  extremely  apt 
to  give  rise  to  infection  provided  the  micro-organisms  they  contain  are 
pathogenic  and  remain  capable  of  development. 

The  modern  artillery  projectiles,  such  as  grenades,  cannon  balls, 
shells,  etc.,  often  give  rise  to  severe  injuries  similar  to  those  caused  by 
machinery  in  times  of  peace ;  entire  extremities  may  be  torn  from  the 
body,  and  death  can  be  instantaneous.  But  slight  wounds,  such  as 
contusions  and  superficial  lacerated  wounds,  are  likewise  frequently 
caused  by  the  same  missiles. 

The  gunshot  injuries  of  bone  are,  as  a  rule,  (1)  comjjound  com- 
Tninuted  fractures.  The  number  of  fragments  is  sometimes  very  large, 
and,  in  addition,  there  are  many  fissures,  as  illusti'ated  in  Figs.  390, 
394-396,  464.  The  splinters  of  bone  are  often  driven  into  the  soft 
parts  or  even  through  the  skin,  forming,  as  we  stated  before,  several 
exit   openings.     Not   infrequently  the    bone   is   crushed   to   a   pulp. 


loi 


INJURIES  AND   DISEASES  OF  JOINTS. 


Fig.  464. — Gunshot  injury  of  the  skull  (in  a 
Russian  soldier  killed  in  the  battle  of 
Plevna),  with  numerous  fissures  which  run 
from  one  opening  (a)  to  the  other  (b)  (Berg- 
mann). 


There  are  also  found  in  bone  (2)  tulndar  op  circular  gunshot  wounds, 
with  or  without  splinters  or  fissures.      The  latter,  in  Fig.  46-1,  unite 
the  points  a  and  h  of  entrance  and  exit  of  the  missile.     (3)  Suhcuta- 
^^  neous  fractures  caused  by  a  sjjent 

ball  have  already  been  spoken  of. 
The  mildest  form  of  injury  to 
bone  is  (4)  contusion,  with  an  ex- 
travasation of  blood  into  the  peri- 
osteum and  bruising  of  the  bone 
substance.  Sometimes  hollows  or 
depressions,  together  with  fissures, 
are  formed  in  the  bone  against 
which  the  bullet  is  flattened  out, 
or  the  latter  is  found  impacted, 
being  in  some  cases  split  in  two 
and  seated  astride  of  the  broken 
edge  of  a  fragment. 

•In  rare  instances  a  gunshot 
fracture  takes  place  not  directly 
at  the  point  where  the  bullet 
strikes  the  bone,  but  at  some  dis- 
tance from  it,  and  either  exists  by  itself  or  is  combined  with  a  fracture 
at  the  point  where  the  bullet  struck  (Lacronique).  These  indirect  gun- 
shot fractures  may  result  from  a  bend,  a  twist,  or  concussion  of  the 
bone  in  question,  and  occasionally  by  a  union  of  several  of  the  fissures 
which  radiate  from  the  point  where  the  bone  has  been  struck  by  the 
bullet. 

Gunshot  injuries  of  joints  are  in  the  main  complicated  wounds 
with  or  without  injury  of  bone.  The  most  severe  gunshot  injuries  of 
the  joints  are  those  with  splintering  of  the  articular  ends  of  the  bones. 

The  Eflfects  produced  by  Modern  Projectiles.— Bush,  Kocher,  and  others 
have  made  some  interesting  experiments  pertaining  to  the  action  of  projec- 
tiles constructed  of  lead  and  the  kind  of  damage  they  cause  in  the  tissues ; 
and  Eeger  has  recently  studied  the  action  of  such  projectiles  upon  bone,  and 
has  come  to  some  practically  important  conclusions.  In  the  case  of  injui'ies 
made  by  soft  lead  within  a  range  of  four  hundred  metres,  an  effect  is  pro- 
duced which  is  like  an  explosion  ;  the  wound  is  finmel-shaped,  and  the  bone 
is  crushed  to  fragments,  which  penetrate  the  soft  parts  posteriorly,  making 
the  Oldening  where  the  projectile  emerges  ten  to  twenty  times  as  large  as  the 
opening  where  it  entered.  In  the  case  of  gunshot  wounds  made  at  a  range 
of  five  hundred  to  one  thousand  metres,  a  clean-cut,  penetrating  wound  is 
made,  with  or  without  radiating  fissures.  If  the  projectile  traverses  the  lon- 
gitudinal axis  of  the  bone,  extensive  splintering  of  the  latter  may  be  pro- 


§  124.]  GUNSHOT  INJURIES.  75 9 

duced.  In  the  case  of  Avounds  made  at  a  range  of  one  thousand  to  fifteen 
hundred  metres,  comminuted  fractures  with  considerable  shattering  of  bone 
not  infrequently  occur  in  spite  of  the  diminished  momentum  of  the  pi'ojec- 
tile.  At  longer  ranges  thei^e  is  a  slight  splintering  or  contusion  of  the  bone, 
in  which  the  bullet  will  often  be  found  impacted. 

The  Action  of  Projectiles  of  Small  Calibre  (Eight  Millimetres  in 
Diameter)  with  a  Steel  Coating.— Chauvel,  Bovet,  Kocher.  and  others  have 
made  experiments  on  the  cadaver  and  living  animals  with  the  small- 
calibre  (eight  millimetres  in  diameter)  projectiles  covered  with  nickel  or 
steel,  which  are  in  general  use.  All  the  experiments  show  that  these  pro- 
jectiles have  a  great  penetrating  power  on  account  of  tlieir  tremendous 
velocity,  and  this  has  been  still  further  increased  by  the  use  of  smoke- 
less powder.  The  projectiles  which  are  coated  Avith  steel  retain  their 
shape,  while  those  made  of  lead  become  deformed  on  account  of  their 
comparative  softness.  At  short  ranges,  however,  the  action  of  the  projec- 
tiles which  are  covered  with  steel  and  those  made  entirely  of  lead  is  very 
much  the  same,  except  that  the  penetrating  power  of  the  former  is  greater ; 
for  example,  three  cadavers  ijlaced  fifty  centimetres  behind  one  another 
were  shot  through  at  a  range  of  six  hundred  metres  (Demosthen).  Accord- 
ing to  Bruns,  these  steel-coated  projectiles  can  pass  through  iron  plates 
twelve  millimetres  in  thickness,  or  pine  wood  one  hundred  and  ten  centi- 
metres thick,  at  a  range  of  twelve  metres.  At  a  distance  of  fifty  metres  the 
bullet  penetrates  tree-trunks  sixty  centimetres  in  diameter.  It  only  rarely 
happens  that  a  steel-coated  bullet  remains  in  the  body.  Even  at  ranges  of 
twelve  hundred  metres  up  to  two  thousand  metres  it  passes  completely 
through  the  body.  The  steel-coated  bullet,  in  case  it  does  not  lose  its  cover- 
ing by  first  striking  some  hard  object,  such  as  a  rock,  keeps  its  form  and 
makes  smooth  wounds  in  the  soft  parts  with  small  entrance  and  exit  open- 
ings. It  is  more  resistant  than  the  nickel  bullet.  At  a  range  of  four  hun- 
dred metres  Bruns  found  that  it  produced  an  effect  like  an  explosion  upon 
the  skull  only,  the  long  hollow  bones  not  suffering  such  extensive  injury; 
at  a  range  of  eight  hundred  metres  perforating  wounds  occurred  :  and  even 
at  a  range  of  twelve  hundred  metres  two  or  tkree  parts  of  a  body  placed  one 
behind  the  other  were  completely  shot  through.  The  projectiles  rarely 
remain  in  the  body,  as  Hobart  and  Chauvel  have  noted  by  experiments 
made  at  ranges  as  long  as  fifteen  hundred  to  two  thousand  metres.  In 
general,  the  modern  i^rojectiles  of  small  calibre  which  are  covered  with 
steel  are  more  humane  than  those  made  entirely  of  lead,  and,  except  at  the 
ranges  where  explosion  of  the  projectile  takes  place,  the  wounds  they  make 
have  a  more  favourable  prognosis,  since  the  bullets  do  not  become  shat- 
tered, but  make  a  smooth  puncture  with  small  openings.  The  firearm  of 
small  calibre  is  the  most  powerful  Aveapon  of  modern  times,  on  account 
of  its  great  velocity,  long  range,  and  tremendous  x^enetrating  power. 

The  observations  made  upon  the  living  Avith  projectiles  of  eight  milli- 
metres diameter  correspond  very  closely  with  the  above  experiments.  Up  to 
certain  ranges  (twelve  hundred  to  two  thousand  metres)  projectiles  which 
strike  the  body  directly  pass  entirely  through  it,  forming  small  openings  at 
their  points  of  entrance  and  exit ;  but  if.  before  entering  the  body,  tliey  re- 
bound from  a  rock  or  piece  of  iron,  they  rarely  do  this.     In  these  rebounding 


760  INJURIES  AND  DISEASES  OF  JOINTS. 

shots  the  steel-coveved  bullets  lose  their  shape  and  become  bent,  the  steel 
covering  bursts,  etc.,  and  accordingly  the  wounds  they  make  are  torn  and 
mangled,  and  the  openings  they  form  on  enteriaig  and  coming  out  are  much 
larger.  Certain  varieties  of  bullets  have  an  especially  destructive  action  upon 
the  tissues.  Of  these  the  bullets  with  a  partial  nickel  covering  (lead-tip  bul- 
lets), the  so-called  dum-dum  bullets,  and  the  hollow-tip  bullets  are  the  best 
known.  The  reports  of  the  English  surgeons  Davies  and  Hamilton,  and  the 
expei'iments  of  Bruns  and  "Wendell,  show  that  the  lead-tip  bullets,  particularly 
when  fired  at  close  range  (two  hundred  to  five  hundred  metres)  cause  very 
severe  wounds — i.  e.,  much  more  laceration  of  the  soft  parts,  and  more  com- 
minution of  the  bone  than  the  usual  completely  coated  bullets.  This  ex- 
plosive action  of  the  lead-tip  bullets  is  explained  by  the  fact  that  the  exposed 
lead  tip  changes  its  form  in  passing  through  the  body,  bi'eaks  the  steel  coat- 
ing into  small  and  minute  pieces,  and  the  lead  aLso  breaks  into  small  frag- 
ments, particularly  when  the  bullet  strikes  bone.  The  hollow-tip  bullets 
have  a  similar  action.  At  short  range  they  cause  a  great  deal  of  destruction, 
particulai'ly  in  the  viscera  that  are  filled  with  fluid.  The  use  of  both  kinds 
of  bullets  in  war  should  be  strongly  pi'otested  against. 

The  Course  of  Gunshot  Wounds. — The  course  of  gunshot  wounds  may- 
be inferred  from  what  we  have  already  said  of  injuries  to  the  soft  parts, 
bones,  and  joints,  and  the  reader  is  referred  to  the  paragraphs  which 
treat  of  these  subjects.  The  pain  is  usually  trifling,  as  the  wound  is 
made  so  quickly,  and  often  a  person  does  not  know  that  he  has  been 
hurt  until  he  notices  the  blood.  The  hfemorrhage  may  be  very  slight 
even  when  large,  deep-seated  arteries  have  been  injured,  and  it  ceases 
spontaneously  by  the  formation  of  a  thrombus  and  by  the  pressure  of 
the  surrounding  parts.  In  other  cases  the  wounded  person  dies  in  a 
few  minutes,  or  even  sooner,  if  a  large  artery  such  as  the  femoral  or 
the  carotid  has  been  divided. 

The  subsequent  course  of  a  gunshot  wound  depends  upon  whether, 
at  the  time  of  the  injury  or  afterwards,  infectious  substances  (bacteria) 
have  gained  access  to  the  wound  by  means  of  dirt  of  various  kinds, 
pieces  of  clothing,  or  unclean  fingers,  instruments,  etc.  The  tempera- 
ture of  the  projectile  at  the  moment  when  it  struck  the  body  is  another 
matter  which  has  an  important  bearing  upon  the  course  of  the  wound, 
as  the  micro-organisms  are  often  killed  by  the  heat  of  the  ball,  espe- 
cially if  it  is  of  small  calibre  and  has  a  nickel  or  steel  covering.  Hence 
infection  of  gunshot  wounds  on  the  battle-field  is  almost  always  due  to 
the  fact  that  immediately  after  the  injury,  or  not  until  later,  micro- 
organisms gain  access  with  the  dirt,  or  from  insufficiently  disinfected 
fingers  and  instruments.  This  infection  may  give  rise  to  the  various 
diseases  of  wounds,  such  as  progressive  inflammation  and  suppuration, 
sepsis,  and  pyaemia.  Tetanus  is  also  not  infrequently  observed,  espe- 
cially if  earthy  materials  have  come  in  contact  with  the  wound.     If, 


§  124.]  GUNSHOT  INJURIES.  761 

however,  infection  does  not  take  place,  even  very  extensive  injuries  to 
bones  and  joints  heal  readily. 

Gunshot  wounds  inflicted  at  a  short  range,  in  which  both  soft  parts 
and  bone  are  badly  mangled,  have  the  worst  prognosis,  and  in  many 
cases,  especially  in  wounds  involving  the  trunk,  head,  or  abdomen, 
death  is  instantaneous.  If  a  patient  with  such  a  gunshot  wound  of  an 
extremity  remains  alive,  a  conservative  plan  of  treatment  is  usually 
hopeless,  and  amputation  or  disarticulation  is  indicated.  It  has  already 
been  remarked  that  the  modern  steel-coated  projectile  of  small  calibre, 
in  spite  of  its  great  penetrating  power — leaving  out  of  consideration 
the  range  within  which  it  explodes — makes  a  cleaner  wound  than  the 
old-fashioned  soft  lead  projectile,  which  mangles  and  lacerates  both 
bone  and  soft  parts.  The  steel-coated  bullet  retains  its  form  in  case 
it  does  not  first  strike  a  rock,  etc.,  and  causes  smooth  non-contused  and 
non-lacerated  wounds.  These  bullets  often  heal  up  in  the  tissues  with- 
out reaction,  and  not  infrequently  change  their  location,  coming  to  the 
surface  at  some  other  part  of  the  body.  Kiister  observed  chronic  lead- 
poisoning  result  from  a  bullet  that  had  remained  in  the  tibia  for  seven- 
teen years. 

Treatment  of  Gunshot  Wounds.— Gunshot  wounds  are  treated,  in 
general,  according  to  the  same  principles  which  we  have  already  given 
for  the  treatment  of  injuries  to  the  soft  parts,  bones,  and  joints. 
Nevertheless,  I  shall  discuss  the  treatment  of  gunshot  wounds  some- 
what more  at  length,  with  particular  reference  to  their  treatment  in 
times  of  war.  For  the  special  treatment  of  penetrating  wounds  of 
the  head,  thorax,  and  abdomen  the  reader  is  referred  to  the  Regional 
Surgery. 

We  think  with  a  shudder  of  that  period  of  the  middle  ages  when 
gunshot  wounds  were  wrongly  looked  upon  as  poisoned  wounds,  and 
were  therefore  burned  out  with  boiling  oil  in  order  to  destroy  the 
venom  of  the  powder.  Ambroise  Pare  and  Maggi  successfully  com- 
bated this  method  of  treatment  in  1551  and  1552.  The  story  is  told 
that  when  the  army  of  King  Francis  of  France  stormed  the  little  castle 
of  Yillane,  near  Susa,  Ambroise  Pare  did  not  have  sufficient  hot  oil  at 
hand  to  burn  out  all  the  gunshot  injuries  in  accordance  with  the  treat- 
ment then  in  vogue.  On  the  next  day  all  those  w^ounds  which  had  not 
been  burned  out  with  oil  were  free  from  pain  and  inflammatory  swell- 
ing, while  those  which  had  been  thus  treated  were  very  painful  and 
much  swollen.  After  this  experience  Pare  always  denounced  this 
cruel  method. 

Every  gunshot  injury  should,  of  course,  be  treated  according  to 
antiseptic  principles,  although  this  is  quite  a  diflierent  thing  in  times  of 


702  INJURIES  AND  DISEASES  OF  JOINTS. 

2)eace  from  what  it  is  in  war.  when,  on  account  of  the  great  numbers 
of  the  wounded,  it  is  not  possible  to  attend  to  every  case  as  carefully 
as  we  are  ordinarily  accustomed  to.  It  is  hence  very  natural  that  the 
expectant  treatment  of  gunshot  injuries  has  been  recommended  again, 
particularly  for  the  first  few  days  after  the  battle.  This  does  not  apply 
to  the  very  severe  injuries  which  require  immediate  operative  interfer- 
ence (see  page  764).  The  expectant  treatment  applies  chieflj^  to  gun- 
shot injuries  with  bullets  of  small  calibre.  Generally  speaking,  the 
ordinary  rules  of  aseptic  surgery  are  also  applicable  to  military  practice. 

It  is  especially  important  to  check  the  haemorrhage  and  remove 
all  foreign  bodies  that  may  have  got  into  the  wound,  such  as  bullets, 
unclean  pieces  of  clothing,  etc.  But  it  is  a  bad  plan  to  hunt  for  a 
bullet  too  industriously  or  too  long,  as  it  subsequently  heals  up  in  the 
tissues,  just  like  other  foreign  bodies.  Deraentjew  and  Bergmann  saw 
in  the  Russo-Turkish  War  eighteen  cases  in  which  the  ball  healed  up 
within  the  knee-joint.  Subsequently  the  projectiles  sometimes  leave 
their  original  positions  and  wander  about,  like  needles  or  other  simi- 
lar bodies.  Bergmann  and  Reyher  made  very  successful  use  of  the 
expectant  treatment  during  the  Russo  -  Turkish  War,  even  in  cases 
of  injuries  involving  joints.  They  confined  themselves  to  a  dis- 
infection of  the  wound  and  its  neighbourhood,  and  then  immobilised 
tbe  extremity  in  plaster  of  Paris  with  or  without  an  antiseptic  occlu- 
sive dressing.  The  parts  often  united  j9e/'  priraaTn  intention  em,  the 
bullet  becoming  enclosed,  while  in  other  instances  suppuration  took 
place,  and  yet  the  bullet  remained  where  it  was.  The  expectant  plan 
of  treatment  may  be  accompanied  by  dangers  when  there  are  pieces  of 
clothing  in  the  wound  ;  but  these  form  the  minority  of  cases,  and 
there  are  usually  no  such  sources  of  infection  present.  If  one  decides 
to  adopt  operative  measures  and  enlarge  the  wound,  in  order  to  check 
hseraorrhage,  for  example,  or  on  account  of  inflammation  or  suppura- 
tion, one  must,  of  course,  proceed  according  to  general  antiseptic 
principles.  In  civil  practice  one  will  not  make  so  much  use  of  the 
expectant  form  of  treatment  for  gunshot  fractures,  but  "will  follow 
the  ordinary  rules  which  govern  the  management  of  compound  frac- 
tures. In  cases  of  wounds  with  extensive  mangling  of  the  soft  parts 
and  bone,  conservative  treatment  is  usually  hopeless,  and  amputation 
is  in  general  indicated. 

It  is  especially  important  that  the  wound  should  not  be  examined 
with  fingers  or  instruments  which  have  not  been  disinfected,  except, 
perhaps,  in  the  face  of  serious  hsemori-hage  which  threatens  the  pa- 
tient's life.  Many  a  wounded  person  has  lost  his  life  through  exam- 
ination of  his  injury  with  a  finger  or  a  probe  which  had  not  been 


§  124.]  GUNSHOT  INJURIES.  763 

properly  disinfected.  Reyher  is  right  in  discriminating  between  "fin- 
gered" wounds — i.  e.,  those  which  have  already  been  examined  by 
a  physician — and  "  unfingered  "  wounds — i.  e.,  those  which  come  di- 
rectly under  the  surgeon's  care.  Out  of  eight  patients  with  "fingered  " 
injuries  of  the  knee,  six  died  and  one  was  in  great  peril,  while  of  seven 
"unfingered"  injuries  of  the  knee  six  recovered. 

The  primary  antiseptic  treatment  consists  either  of  antiseptic  occlu- 
sion of  the  wound  in  the  skin  or  antiseptic  drainage.  In  the  former — 
i.  e.,  in  healing  under  a  scab — all  exploration  of  the  wound  with  a  probe 
or  the  finger  should  as  far  as  possible  be  avoided.  If,  however,  an  ex- 
ploration of  the  wound  is  absolutely  necessary  on  account  of  dangerous 
haemorrhage,  infection  of  the  wound,  etc.,  drainage  must  at  the  same 
time  be  provided  for,  and  any  operative  measures  which  may  be  neces- 
sary, such  as  removal  of  splinters  of  bone,  resection,  or  amputation, 
must  be  undertaken  at  once.  An  excellent  method  of  drainage  in  case 
of  large  gunshot  wounds  is  to  pack  the  latter  with  iodoform  gauze  or 
sterilised  mull.  Every  gunshot  wound  is  treated  by  the  open  method — 
i.  e.,  is  not  sutured.  The  best  antiseptic  for  military  practice  is  bichlo- 
ride of  mercury.  The  dressing  should  be  as  simple  as  possible.  In 
some  countries  the  soldier  is  supplied  with  the  material  for  the  first 
dressing  in  the  form  of  a  small  bundle  which  can  be  sewed  into  his 
coat  or  carried  in  the  breast  pocket  or  knapsack.  I  think  this  plan 
of  letting  each  soldier  apply  the  first  dressing  with  the  materials  which 
he  carries  with  him  is  a  bad  one,  since  these  dressings  are  anything 
but  antiseptic — in  fact,  they  are  usually  full  of  dirt.  It  is  much  bet- 
ter that  there  should  be  a  large  number  of  surgeons  and  well -trained 
assistants  upon  the  field  furnished  with  sufiicient  antiseptic  dressing 
materials,  and  that  the  dressings  which  the  soldiers  carry  witb  them 
should  only  be  used  in  an  emergency.  These  consist  of  two  pieces  of 
compress  impregnated  with  bichloride,  one  bandage,  a  safety  pin,  and 
a  three-cornered  piece  of  cloth,  all  of  which  are  wrapped  up  in  some 
rubber  material.  In  order  that  antisepsis  may  be  properly  observed  in 
time  of  war  all  persons  entrusted  with  the  care  of  the  wounded  should 
be  previously  instructed  in  the  general  principles  of  antiseptic  treatment 
and  in  the  technique  of  applying  simple  antiseptic  dressings.  The  vol- 
untary assistance  of  persons  in  the  higher  walks  of  life,  especially  stu- 
dents, is  very  desirable  in  this  connection. 

The  sterilisation  of  dressings  can  be  carried  out  in  times  of  war 
according  to  the  same  principles  as  in  times  of  peace,  and  hence  it  is 
not  a  good  plan  to  make  a  collection  beforehand  of  dressing  materials 
which  have  been  impregnated  with  antiseptics,  as  they  will  be  subse- 
quently found  to  contain  bacteria  in  spite  of  the  best  of  packing.    The 


704  INJURIES  AND   DISEASES   OF  JOINTS. 

most  suitable  kind  of  dressings  are  those  which  can  be  transported  in 
the  smallest  possible  bulk,  such  as  mull,  hemp,  and  cotton.  The  com- 
mon salt-bichloride  tablets  "which  Angerer  has  recently  recommended 
for  military  practice  are  verv  useful,  and  greatlj  facilitate  the  prepa- 
ration of  permanent  bichloride  solutions.  Instead  of  sponges,  aseptic 
gauze  pads  are  to  be  recommended. 

On  the  battle-field  the  wounded  are  first  carried  to  a  covered  place 
marked  by  the  red  cross  flag,  which  is  the  first  dressing  place.  The 
wounded  are  dressed  here  provisionally,  and  in  some  cases  pennanent 
dressings  are  put  on.  From  here  they  are  moved  to  the  nearest  field 
hospital.  The  dressings  at  tlie  first  dressing  station  are  applied  accord- 
ing to  the  rules  of  antisepsis ;  not  only  sterile  dressings  are  used,  but 
also  antiseptic  powders,  such  as  iodoform,  dermatol,  etc.  The  duties 
at  the  first  dressing  place  consist  in  the  prevention  of  wound  infection, 
in  conservative  treatment  of  gunshot  injuries — e.  g.,  of  the  extremities 
— and  in  immediate  interference  in  the  case  of  dangerous  injuries  (arrest 
of  haemorrhage,  ligation  of  large  vessels,  amputation,  tracheotomy). 
At  the  first  j^lace  only  the  most  necessary  life-saving  operations  should 
be  performed.  The  most  seriously  wounded,  especially  those  who  can- 
not get  to  the  first  dressing  place,  should  be  attended  to  first.  It  has 
been  said  that  in  future  battles  the  disproportion  between  the  number 
of  the  injured  and  that  of  the  surgeons  will  be  even  more  evident  than 
it  has  been  in  the  past,  as  the  rapid-firing  guns  now  used,  on  account  of 
the  greater  accuracy  of  their  aim,  will  probably  increase  the  numljers 
of  the  wounded,  while  the  number  of  surgeons  will  remain  aljout  the 
same.  Billroth  likewise  expressed  the  fear  that  the  number  of  wounded 
in  coming  battles  will  be  so  great  that  there  mil  not  be  sufficient  help 
at  hand  to  render  them  the  necessary  assistance  while  the  battle  is 
going  on.  In  my  opinion,  however,  there  is  no  ground  for  these  fears. 
In  spite  of  the  increasing  perfection  of  the  guns  used  in  the  modern 
battles  the  latter  are  less  bloody,  for  the  reason  that  fighting  at  close 
range  has  become  rarer,  and  the  protection  of  the  ground  is  made  more 
use  of  than  formerly.  The  bloodiest  battle  of  the  nineteentli  century 
is  said  to  have  been  the  battle  of  Leipsic,  where  there  were  90,000 
killed  and  wounded;  the  next  bloodiest  was  the  battle  of  Aspem, 
in  which  there  was  a  total  loss  of  66,000;  and  then  Borodino,  with 
62,000.  Aspern  had  the  highest  percentage  of  killed  and  wounded 
(38  per  cent.) ;  then  come  Borodino,  with  25  per  cent. ;  Eylau  and 
Waterloo,  with  24  per  cent. ;  Leipsic  and  Inkerman,  with  21  per  cent. 
On  the  other  hand,  the  relative  loss  in  dead  and  wounded  at  Konig- 
gratz  was  Y.5  per  cent.,  at  Gravelotte  16  per  cent.,  at  Sedan  12  per 
cent.,  at  Worth  13.5,  at  Mars  la  Tour  16  per  cent.,  and  at  Plevna  14 


§  124.]  GUNSHOT  INJURIES.  Y65 

per  cent.  These  figures  give  the  percentage  for  both  armies.  If  we 
examine  the  losses  of  the  se|)arate  armies — e.  g.,  on  the  German  or 
French  side — we  find  here  also  that  the  o-reatest  losses  in  the  larg-e  bat- 
ties  of  modern  times  were  smaller  than  thej  used  to  be,  and  have  never 
reached  a  fourth  of  the  whole  strength  of  the  array.  The  Germans  lost 
at  Mars  la  Tour  22  per  cent.,  the  French  at  Worth  16  j>ev  cent.,  and 
at  Sedan  19  per  cent.  The  Austrians  lost  at  Koniggratz  11  per  cent., 
and  the  Russians  at  Plevna  IT  per  cent. 

But  quite  apart  from  the  fact  that  battles  in  modern  times  are  less 
bloody  than  they  used  to  be,  the  German  army  organisation  has  pro- 
vided for  a  sufficient  number  in  the  hospital  corps  to  render  first  aid 
to  the  wounded.  Haase  states  that  the  organisation  for  the  care  of  the 
wounded  which  the  German  army  possesses  will  amount  in  future  wars 
to  forty -five  thousand  well-trained  men  (hospital  orderlies,  carriers  of 
the  wounded,  etc.).  Thus  we  can  see  that  a  liberal  provision  has  been 
made.  At  the  field  hospitals,  which  are  usually  churches,  school- 
houses,  or  other  large  buildings,  or  tents  and  barracks,  the  wounded 
who  are  brought  in  with  temporary  dressings  on  are  examined  with 
antiseptic  precautions  and  permanent  dressings  then  applied,  and,  when 
necessary,  the  wounds  are  enlarged,  drained,  and  disinfected.  Those 
who  have  thus  been  dressed  antiseptically  are  then  transported  to  a  per- 
manent hospital.  During  transportation  injured  portions  of  the  body, 
especially  gunshot  fractures,  must  be  immobilised  as  thoroughly  as 
possible  (see  §  53  and  page  220). 

In  addition  to  permanent  buildings,  such  as  schoolhouses  and 
churches,  tents  and  the  so-called  Docker's  barracks  are  particularly  well 
adapted  for  quarters  for  the  wounded.  Haase  states  that  an  army  of 
100,000  men  needs  601  movable  and  167  stationary  barracks  to  furnish 
room  for  from  15,000  to  18,000  wounded.  Some  of  the  barracks  used 
for  war  purposes  are  made  of  felt  (Docker's  barracks),  while  others  are 
tents  or  wooden  sheds.  Haase  is  right  in  recommending  that  these 
tents  and  barracks  be  put  in  position  by  bodies  of  men  organised  for 
that  purpose  and  under  the  command  of  special  officers.  In  a  future 
war  the  tents  will  play  an  important  part  in  the  care  of  the  wounded. 
The  tents,  in  case  they  are  used  on  the  battle-field,  can  be  made  from 
the  portable  tent  supplies  of  the  soldiers,  or  they  can  be  transported  by 
rail  to  the  points  where  they  are  to  be  put  up. 

"We  have  not  space  to  take  up  more  in  detail  the  first  treatment  of 
the  wounded  on  the  battle-field,  but  whoever  is  interested  in  this  sub- 
ject should  consult  the  books  which  have  been  written  upon  it  by  Es- 
march  and  Port.  A  very  excellent  and  exhaustive  treatise  on  military 
surgery  will    be    found   in    Fischer's    Handbuch  der  Kriegschii'urgie 


766 


INJURIES  AND  DISEASES  OF  JOINTS. 


For  a  description  of  the  easily 
have  devised  for  military  prae- 


(Deutsche  Cliirurgie,  Stuttgart,  1SS2). 
transportable  operating  table  which  I 
tice,  see  page  T,  Figs.  5  to  7. 

Search  for  a  Bullet.— In  searching  for  a  bullet  one  may  use  the  disinfected 
finger  or  an  ordinary  probe,  and  in  the  case  of  very  deep  wounds,  long, 
curved  or  straight  dressing  forceps,  silver  catheters,  etc.  Graham  Bell  has  in- 
vented an  electric  probe  for 
finding  bullets.  A  needle 
which  has  been  insulated 
by  coating  all  but  its  point 
with  varnish  is  inserted  into 
the  region  where  the  pres- 
ence of  the  projectile  is  sus- 
pected and  then  connected 
with  the  end  of  a  telephone 
wire.  A  metallic  plate  of 
the  same  material  as  the 
needle  is  fastened  to  the  end 
of  the  other  wire  and  ap- 
plied to  the  skin  in  tlie 
neighbourhood  of  the  bul- 
let. If  the  point  of  the  nee- 
dle comes  in  contact  with 
the  ball  the  circuit  is  closed, 
and  every  time  they  come 
together  a  distinct  noise 
is  heard  in  the  telephone. 
Klein  has  constructed  a  sim- 
ilar electro  -  microphonic 
searcher  (see  Aerztl.  Poly- 
technik,  March,  1892).  The 
magnetic  needle  can  also  be 
used  in  suitable  oases  for 
finding  a  ball  even  after  it 
has  become  healed  up  in  the  tissues,  and  is  especially  applicable  to  the  search 
for  the  modern  steel-coated  pi-ojectiles.  Gartner  recommends  that  the  steel- 
covered  bullet  which  has  entered  the  body  be  first  magnetised  by  stroking 
the  area  in  question  with  a  powerful  magnet.  By  means  of  a  sensitive  mag- 
netic needle — i.  e.,  a  pair  of  astatic  needles  suspended  by  a  silk  thread,  or 
Lamont's  magnetoscope — the  point  on  the  skin  is  determined  to  which  the 
ball  or  iron  splinter  lies  nearest  (Kocher,  Gartner,  Sachs).  Gartner  con- 
structed an  astatic  magnetic  needle  out  of  a  magnetised  sewing  needle  which 
he  broke  in  two,  a  straw,  and  a  piece  of  silk  thread,  and  made  successful  use 
of  it  in  finding  projectiles  after  having  first  magnetised  them.  The  old-fash- 
ioned probe  invented  by  Nelaton  has  a  knob  made  of  porcelain  which  is  made 
black  by  contact  with  the  bullet. 

Importance  of  the  X-rays  in  Surgical  Diagnosis.— The  existence  of  this 
new   form   of  vibration   of  ether  was  discovered  by  Professor  Rontgen  in 


Fig.  46.5. — X-ray  photograph  of  a  right  hand :   a,  pistol 
bullet  between  the  fourth  and  fifth  metacarpal  bones. 


134] 


GUNSHOT  INJURIES. 


m 


Wlirzburg.  Pig.  465  shows  an  X-ray  photograph  of  the  hand  ;  the  soft  parts 
are  permeable  to  the  Eontgen  rays,  while  the  bones,  the  ring  on  the  fourth 
finger,  and  the  bullet  that  is  healed  in  between  the  fourth  and  fifth  meta- 
carpus are  impermeable  and  stand  out  clearly.  The  X-rays  are  of  great  im- 
portance in  surgical  and  medical  diagnosis,  particularly  for  locating  foreign 
bodies  in  the  tissues  (needles,  bullets,  renal  calculi,  vesical  calculi,  etc.),  and 
for  injuries  and  diseases,  and  congenital  and  acquired  deformities  of  bones 
and  joints.  By  the  aid  of  the  new  improved  apparatus  the  minute  structure 
of  the  bone  can  be  shown  in  a  photograph.  It  would  have  much  greater 
diagnostic  value  if  it  could  show  diiferences  in  the  tissues  of  the  various 


Fig.  466. — X-ray  photograph  of  a  left  hand  containing  numerous  pieces  of  lead.  The  patient 
was  wounded  thirty  years  before  in  battle  by  splinters  of  lead  from  a  bullet  which  struck 
his  gun. 


organs.  The  X-rays  have  also  been  used  therapeutically — for  example,  in  the 
treatment  of  lupus  and  other  skin  diseases.  After  an  expei'ience  of  several 
years  with  the  X-rays  we  can  say  that,  though  they  have  not  fulfilled  the 
extreme  expectations  of  the  most  sanguine  enthusiasts,  they  nevertheless 


768  IXJUKIES  AND  DISEASES  OF  JOINTS. 

occupy  a  permanent  place  as  a  valuable  method  of  diagnosis,  and  every  hos- 
pital should  possess  the  necessary  appai"atu3. 

Projectiles  are  extracted  by  means  of  foi'ceps,  or  siDoon-shaped  instru- 
ments. The  most  simple  kind  are  the  long,  curved  or  sti-aig-ht  dressing  for- 
ceps, or  long,  narrow  forceps  with  sharp-pointed  teeth  which  cover  one  an- 
other when  closed,  so  that  they  do  not  injure  the  tissues.  The  best-known 
sjioon-shaped  instruments  are  Thomassin's  and  Langenbeck's.  Elevators  can 
also  be  employed  for  this  purpose.  Formerly,  if  the  ball  were  firmly  em- 
bedded in  the  bone,  it  was  extracted  by  screws  or  augers,  which  were  bored 
into  the  lead  like  corkscrews.  These  augers  and  screws,  and  the  forcejDS 
with  the  sharp-pointed  teeth,  are  no  longer  used  for  the  modei*n  steel-coated 
projectiles,  having  been  superseded  by  narrow,  straight,  or  curved  forceps. 
The  steel-covered  projectiles,  however,  remain  lodged  in  the  body  much 
more  rarely  than  the  lead  bullets ;  they  usually  pass  entirely  through  it  and 
emerge  externally. 


CHAPTEK  Y. 


TUMOURS. 


Tumours  in  general. — Definition  and  classification  of  tumours. — Etiology  of  tu- 
mours.— Clinical  features,  diagnosis,  prognosis,  and  treatment. — The  anatomical 
structure  and  clinical  course  of  the  different  varieties  of  tumours,  with  their 
treatment. 

§  125,    Tumours    in    General — Definition    and    Classification. — The 

study  of  tumours  forms  one  of  the  most  interesting  chapters  of 
pathology;  but  it  would  require  too  much  space  to  discuss  this  vast 
subject  with  anything  like  com]3leteness,  and  so  we  must  satisfy  our- 
selves with  merely  a  superficial  account  of  such  tumours  and  growths 
as  are  amenable  to  surgical  treatment.  Yirchow  has  done  more  than 
any  one  else  to  advance  our  knowledge  of  tumours,  and  his  work 
entitled  Die  krankhaften  Geschwiilste,  will  always  be  a  glorious 
monument  to  German  research.  Other  successful  workers  in  this 
1)ranch  of  pathology  are  C.  O.  Weber,  Rindfleisch,  Billroth,  Thiersch, 
Waldeyer,  Cohnheim,  and  Ribbert.  For  a  description  of  the  general 
pathology  of  tumours  the  reader  is  referred  to  the  text-books  of  Cohn- 
heim, Klebs,  Orth,  Ziegler,  etc. 

The  question.  What  is  a  tumour  ?  has  received  various  answers. 
In  fact,  it  is  difficult  to  give  a  suitable  definition  which  includes  all 
tumours,  as  they  present  marked  differences  anatomically,  etiologically, 
and  clinically.  Liicke's  definition  has  been  the  most  widely  accepted. 
According  to  him,  we  mean  by  a  tumour  an  increase  in  the  volume  of 
some  portion  of  the  body,  due  to  a  new  formation  of  tissue  which 
reaches  no  physiological  limit,  and  which — to  add  Cohnheim's  words — 
differs  from  the  morphologico-anatomical  type  of  the  locality  where 
it  occurs.  We  distinguish  from  true  tumours  the  hyperplastic,  inflam- 
matory formations,  all  the  infectious  granulation  tumours  of  tubercu- 
losis, syphilis,  leprosy,  etc.,  and  certain  collections  of  fluid  and  cells  in 
preformed  cavities,  such  as  aneurysm,  hygroma  of  tendon  sheaths  and 
mucous  bursse,  hydrocele  of  the  tunica  vaginalis  testis,  and  all  reten- 
tion cysts.     We  yecognise,  as  Cohnheim  does  : 

53  769 


770  TUMOURS. 

1.  Tumours  the  main  portion  of  wliieh  is  of  the  connective-tissue 
type ;  these  include  fibroma,  lipoma,  myxoma,  chondroma,  osteoma, 
angeioma,  Ijmphangeioma,  endothelioma,  lymphoma,  and  sarcoma, 
together  with  mixed  or  combination  tumours  made  up  of  simpler 
forms. 

2.  Tumours  having  the  type  of  muscular  tissue  :  Myoma  Itevicellu- 
lare  and  myoma  striocellulare. 

3.  Tumours  made  up  of  nerve  tissue :  Neuroma  and  glioma. 

•i.  Tumours  of  the  epithelial  type — viz.,  epithelioma,  onychoma, 
adenoma,  cystoma,  and  carcinoma.  There  remains  as  a  subdivision  of 
this  group  the  teratoma  of  Yirchow,  in  which  many  different  kinds  of 
tissue — such  as  hair,  skin,  bone,  teeth,  parts  of  intestine  and  brain — are 
found.     In  this  class  belong  the  dermoid  cysts. 

Birch- Hirschf eld  makes  the  following  classification  :  1.  Connective- 
tissue  tumours ;  2,  muscle  tumours ;  3,  nerve  tumours ;  4,  epithehal 
tumours ;  5,  mixed  or  combination  forms  of  tumours ;  6,  cystic 
tumours,  consisting  of  a  closed  sac  containing  more  or  less  fluid.  This 
group  includes  tumours  which  are  etiologically  and  histologically  very 
different ;  some  of  them  (retention  cysts)  do  not  belong  to  the  prolifer- 
ating tumours  at  all,  while  others  are  due  to  abnormities  of  develop- 
ment (teratoma-dermoid  cysts),  or  originate  secondarily  fi'om  different 
tumours  (cystoma  glandulare,  cystosarcoma).  7.  Infectious  tumours 
(granulation  tumours)  which  are  related  histologically  and  etiologically 
to  the  inflammatory  formations,  and  do  not  belong  among  the  true 
tumours  (products  of  tuberculosis,  syphilis,  leprosy,  etc.). 

§  126.  Etiology  of  Tumours. — The  etiology  of  tumours,  meaning 
thereby  neoplasms,  still  remains  obscure,  although  many  theories  have 
been  advanced  upon  this  subject.  Their  causes  are  partly  direct  and 
partly  indirect  or  predisposing,  the  latter  including  the  effects  of 
age,  sex,  occupation,  etc.  Inherited  predisposition  plays  an  im- 
portant part  in  their  causation,  and  in  many  cases — notably  of  sar- 
coma— Esmarch  believes  that  their  development  depends  upon  a  pre- 
disposition inherited  from  syphilitic  ancestors.  As  direct  causes  of 
tumours,  local  irritations — mechanical,  chemical,  or  inflammatory  in 
nature — have  been  thought  especially  important.  Thus  we  know  that 
a  sarcoma,  for  instance,  occasionally  forms  after  a  severe  contusion,  or 
that  an  epithelioma  of  the  lower  lip  or  of  the  mucous  membrane  of 
the  mouth  develops  in  immoderate  smokers,  or  as  a  result  of  frequently 
repeated  traumatic  irritations  caused  by  a  sharp  tooth,  frequent  shav- 
ing with  dull  razors,  etc.  Sometimes  after  fractures  l^enign  (osteoma, 
chondroma)  and  malignant  tumours  (sarcoma)  develop  in  the  callus — 
the  so-called  callus  tumours.     According  to  Kapok,  one  hundred  and 


§  126.]  ETIOLOGY  OF  TUMOURS.  771 

twenty-eight  out  of  six  hundred  and  sixty-nine  tumours  followed 
injuries.  Ziegler  found  that  in  IS  per  cent,  of  his  cases  of  tumours 
there  had  been  a  single  traumatism,  and  in  25  per  cent,  a  continued 
traumatic  influence.  Lowenthal  found  that  out  of  934  cases  of  mam- 
mary carcinoma  a  history  of  traumatism  was  present  in  125,  or  ISA 
per  cent.  Out  of  70  cases  of  sarcoma  collected  by  Coley  there  were 
11:  in  which  traumatism  played  an  important  part  in  the  etiology.  In 
my  opinion  it  has  not  yet  been  proved  that  a  tumour  can  result  from 
a  traumatism,  but  it  is  undoubtedly  possible,  and  this  theory  is  in  accord 
with  our  theoretical  views  regarding  the  nature  of  tumours.  One 
could  imagine  that  a  traumatism  separates  larger  or  smaller  groups 
of  cells  from  their  connection  with  the  tissues,  thus  removing  them 
from  the  physiological  limits  of  growth  and  allowing  them  to  develop 
a  power  of  growth  of  their  own  and  to  displace  the  normal  tissues  (see 
page  812).  In  other  cases  tumours  are  caused  by  chemical  and  inflam- 
matory irritation — e.  g.,  carcinoma  of  the  tongue  in  great  smokers,  and 
the  carcinomata  that  develop  in  chimney-sweeps  and  workers  in  tar 
and  parafiin  factories.  But  chemical  and  inflammatory  irritation  is 
not  sufficient  in  itself  to  produce  a  tumour.  There  must  be  a  local 
predisposition  to  the  development  of  a  new  growth,  and  this  could  be 
the  same  as  in  the  case  of  traumatisms — i.  e.,  the  cells  are  separated  by 
the  inflammatory  process  from  their  physiological  connections  and 
after  their  displacement  take  on  an  independent  growth.  Sometimes 
disturbances  of  the  nervous  system — trophoneuroses — play  an  impor- 
tant part  in  their  causation.  Buchterkirch  and  Bumke  saw  a  case  of 
multiple,  symmetrical  lipomata  which  followed  a  contusion  of  the  spinal 
cord.  Symmetrical  tumours  have  also  been  seen  in  the  lachrymal 
and  salivary  glands.  In  a  portion  of  these  cases  the  swelling  of  the 
lachrymal  glands  which  occurred  first,  and  later  that  of  the  salivary 
glands,  was  inflammatory  in  nature.  A  preceding  inflammation  has 
a  very  important  influence  upon  the  development  of  neoplasms,  as 
is  shown  in  those  cases  of  carcinoma  of  the  breast  which  follow  a  masti- 
tis. Malignant  tumours,  both  carcinoma  and  sarcoma,  often  originate 
from  simple  warts,  and  melanomata  from  small  patches  of  pigment  in 
the  skin.  Kapok  states  that  one  hundred  and  eighty-two  out  of  three 
hundred  and  ninety-nine  carcinomata  started  in  warts,  and  indeed  one 
third  of  all  the  instances  of  tumours  collected  by  him  (six  hundred  and 
ninety-nine)  had  this  origin.  According  to  Woodhead,  tumours  are 
due  to  a  deficiency — not  a  superfluity — of  nourishment ;  even  though 
there  is  actually  an  increased  amount  of  food  taken  into  the  system, 
this  is  not  able  to  supply  the  needs  of  the  tissues  in  question.  He 
holds  the  view  that  tumours  develop  when,  as  a  result  of  irritations 


772  TUMOURS. 

from  diSerent  sources — such  as  injuries,  parasites,  microbes,  lons;- 
continued  action  of  an  irritating  organic  or  inorganic  substance,  or  a 
simple  chronic  catarrh — so  great  an  increase  in  the  activity  of  the 
tissue  elements  is  demanded  that  the  food  brought  into  the  system 
is  insufficient  to  supply  these  demands.  Schleich  looks  upon  tumour- 
formation  as  a  kind  of  infection  originating  within  the  organism,  a  cell 
at  a  certain  stage  of  its  physiological  development  becoming  infectious 
as  a  result  of  irritations  of  various  sorts.  Analogously  to  the  develop- 
ment of  an  impregnated  ovum,  tumours  are  considered  by  him  as 
products  of  a  pathological  conception  and  impregnation ;  the  patho- 
loo"ical  spermatozoon  is  represented  by  the  cell  that  has  become  infec- 
tious. Many  authorities  think  that  tumours,  particularly  the  malignant 
variety,  are  caused  by  micro-organisms  (protozoa ;  see  also  page  819). 
Jiirgeus  claims  that  there  are  some  sarcomata  which  must  be  regarded 
as  infectious,  as  they  can  be  transmitted  to  animals  by  inoculation. 
Jiiro;ens  found  sj)orozoa  in  both  the  primary  and  secondary  tumours. 

Cohnheim  developed  a  very  ingenious  theory  as  to  the  ultimate  cause 
of  new  growths.  He  thought  this  to  be  an  abnormity  or  irregularity  in 
the  embryonic  rudiment  of  the  part  of  the  body  in  question — in  short, 
that  neoplasms  originate  from  the  growth  of  embryonic  germs  or  ger- 
minal cells  which  have  been,  as  it  were,  shut  up  in  the  normal  tissues. 
In  many  individuals  these  tumour  germs  do  not  become  developed,  but 
in  others  traumatisms,  mechanical  and  chemical  irritation,  or  the  dimin- 
ished powers  of  resistance  possessed  by  the  surrounding  normal  parts, 
increased  blood  supply,  etc.,  may  arouse  them  to  activity.  This  theory 
of  Cohnheim's  seems  very  plausible  for  many  cases,  but  it  lacks  ana- 
tomical foundation  ;  in  fact,  as  Birch-Hirschfeld  says,  a  positive  proof 
of  the  correctness  of  Cohnheim's  hypothesis,  as  applied  to  tumours  in 
general,  is  quite  impossible.  It  is,  however,  unquestionable  that  some 
tumours  spring  from  embryonic  germs,  and  certain  facts  are  very  well 
explained  by  Cohnheim's  theory — viz.,  the  transmission  of  tumours 
by  inheritance,  the  occurrence  of  congenital  tumours,  and  of  certain 
tumours  in  particular  portions  of  the  body,  such  as  epithelial  tumours, 
carcinomata  of  the  lip,  tongue,  cardiac  or  pyloric  orifices  of  the  stom- 
ach, glans  penis,  cervix  uteri,  etc. ;  in  other  words,  in  localities  where 
inversions  of  the  epiblast  in  the  form  of  groups  of  epithelial  cells, 
which  have  strayed  away  during  the  embryonic  period,  may  easily  take 
place.  Cohnheim's  hypothesis  also  furnishes  the  best  means  of  explain- 
ing the  heterologous  origin  of  primaiw  epithelial  tumours  in  organs 
which  do  not  contain  epithelium.  We  know,  for  instance,  that  the 
dermoid  cysts  are  a  result  of  stray  embryonic  germs.  liibbert  has 
recently  developed  Cohnheim's  theory  more  fully.     According  to  him. 


§  127.]  GROWTH,  COURSE,  DIAGNOSIS,  TREATMENT  OF  TUMOURS.     773 

tumours  are  formed  not  onlj  from  strayed  foetal  germs,  but  also  from 
groups  of  cells  that  have  become  separated  in  post-foetal  life  from  their 
organic  connections.  We  shall  return  to  this  theory  under  the  subject 
of  Carcinoma. 

Transmissibility  of  Tumours. — Great  importance  attaches  to  the 
question  whether  or  not  tumours,  especially  malignant  ones  (carcinoma, 
sarcoma),  are  transmissible  in  the  sense  that  living  tumour-cells,  when 
transplanted,  can  give  rise  to  the  development  of  the  same  kind  of 
malignant  tumour  in  that  part  of  a  body  to  which  they  are  transferred. 
Such  a  transmissibility  of  tumours  has  in  fact  been  sufficiently  proved 
in  the  case  of  both  animals  and  man  by  experimental  and  clinical 
observations.  Eiselsberg  successfully  inoculated  rats  with  a  fibro- 
sarcoma. In  regard  to  the  transmissibility  of  carcinoma,  see  page  820  ; 
of  sarcoma  and  melanoma,  see  page  806. 

Etiology  of  Tumours  in  Animals.— Plicque  and  Frohner  have  published, 
in  regard  to  the  origin  of  tumours  in  animals,  some  interesting  facts  which 
show  many  analogies  to  tumour-formation  in  man.  The  real  cause  of 
tumours  in  animals  is,  to  be  sure,  unknown,  as  far  as  the  predisposition  of 
the  bearer  is  concerned ;  but  as  regards  the  direct  cause,  the  following  has 
been  noted :  The  carcinoma  of  the  lip  in  horses  generally  develops  in  the 
corners  of  the  mouth  from  pressure  of  the  bit,  while  in  cats  the  upper  lip  is 
ordinarily  affected  as  a  result  of  the  re^Deated  bites  of  small  animals.  The 
subcutaneous  fibroma  which  is  often  seen  in  horses  is  caused  by  the  pres- 
sure of  the  harness.  Constant  or  frequently  rej)eated  traumatisms  play  an 
important  part  in  the  origin  of  tumours  in  animals,  as  do  also  preceding 
inflammations.  Bitches  suffer  from  carcinoma  of  the  mammary  glands 
much  oftener  than  male  dogs,  and  the  hindermost  glands  are  the  ones  most 
commonly  affected,  as  they  are  particularly  likely  to  be  the  seat  of  a  mastitis. 
The  melanosis  of  horses  is  thought  to  be  transmissible  by  inberitance,  so  that 
mares  or  stallions  which  have  it  cannot  be  used  for  breeding ;  heredity  is 
also  said  to  play  a  part  in  the  origin  of  the  mammary  cancer  of  bitches. 

The  influence  of  age  is  very  noticeable  in  animals.  In  old  dogs  carcino- 
ma is  very  frequent,  while  young  ones  are  practically  immune.  Whether 
the  nutrition  of  the  animal  plays  a  j)art  in  the  tumour-formation,  as  has  been 
thought  to  be  the  case  in  carcinoma  in  man,  cannot,  as  Plicque  says,  be  easily 
decided.  Among  pronounced  carnivora,  like  the  dog,  carcinoma  is  very 
common,  and  herbivora  like  the  horse  are  not  exempt  when  they  reach  an 
advanced  age. 

§  127.  Growth,  Course,  Diagnosis,  and  Treatment  of  Tumours.— The 
growth  of  tumours  takes  place  in  exactly  the  same  way  as  that  of  other 
tissues — by  cell  proliferation.  The  rapidity  of  growth  is  very  variable, 
depending  upon  the  locality,  the  blood  supply,  and  the  structure  of  the 
tumour.  The  more  cells  the  latter  has,  the  more  rapidly  it  grows. 
Localised  or  more  diffuse  disturbances  of  nutrition,  such  as  fatty  degen- 
eration, calcification,  and  colloid  degeneration  or  necrosis,  resulting. 


Y74  TUMOURS. 

perhaps,  in  a  complete  spontaneous  cure  of  the  tumour,  very  frequently 
occur.  Necrosis  in  the  form  of  ulceration  is  exceedingly  common, 
especially  in  carcinomata  which  have  broken  through  the  skin  or 
mucous  membrane.  According  to  Xepveu  and  Yerneuil,  the  soften- 
ino-  of  tumours  is  caused  in  some  instances  by  bacteria.  A  true  tumour 
does  not  disappear  spontaneously  ;  some  remain  stationary,  ^yhile  others 
keep  on  growing  at  a  faster  or  slower  rate.  It  is  an  interesting  fact 
that,  like  fojtal  tissues,  tumours  have  a  more  or  less  abundant  supply 
of  glycogen.  The  most  important  distinction  between  tumours  is  pre- 
sented by  their  clinical  course,  and  this  allows  us  to  divide  them  into 
benign  and  malignant  groM'ths.  The  former  remain  local,  but  the  lat- 
ter penetrate  into  the  neighbouring  tissues  and  destroy  them,  and  the 
tumour  germs,  being  carried  off  in  the  blood  and  lymph,  give  rise  to 
metastatic  or  secondary  neoplasms  in  all  parts  of  the  system,  especially 
the  liver  and  lungs.  Cartilage  is  the  only  tissue  in  which,  so  far  as  I 
know,  no  metastases  have  been  found.  The  metastases  have  essentially 
the  same  structure  as  the  primary  tumours,  and  are  found  either  in 
the  vicinity  of  the  latter — that  is,  in  the  region  supjDlied  by  the  lymph 
and  blood  which  come  directly  from  the  tumour — or  in  distant  organs 
after  the  tumour  germs  have  passed  through  the  heart.  Metastases 
due  to  capillary  emboli  are  most  commonly  caused  by  the  tumour  cells 
which  pass  through  the  lungs  in  the  venous  blood  without  being 
retained  there  (Zahn).  Should  the  germs  be  carried  through  the 
lymph  vessels,  they  usually  become  implanted  in  the  nearest  lymph 
glands  and  here  lead  to  the  development  of  tumour  tissue  which  is 
identical  with  that  of  the  original  neoplasm.  In  this  way  the  infected 
lymph  glands  become  new  foci  for  further  infection  and  development 
of  metastases.  The  tumour  germs  also  enter  the  vascular  system  by  a 
direct  ingrowth  of  the  mother  tumour  into  the  walls  of  the  vessels.  I 
once  saw  a  metastasis  in  a  valve  of  the  femoral  vein  in  a  case  of  sar- 
coma of  the  leg.  Tumours  which  in  other  resjDects  are  benign — such 
as  fibroma,  lipoma,  cystic  goitre,  chondroma,  myoma,  etc. — may  also, 
in  exceptional  instances,  give  rise  to  metastases.  It  is  characteristic  of 
tumour  metastases — especially  those  from  the  I'eally  maHgnant  tumours 
— to  go  on  growing  indefinitely.  Normal  tissue  germs  do  not  have 
this  jjeculiarity,  as  is  shown  by  the  experiments  of  Cohnheim,  Maas, 
etc.  Small  pieces  of  periosteum  and  embryonic  cartilage  implanted  in 
the  circulation,  the  peritoneal  cavity,  or  in  the  anterior  chamber  of 
the  eye,  grow  for  a  time  and  can  thus  give  I'ise  to  very  small  osteomata 
or  enchondromata ;  but  these  soon  disa]j|3fear  without  leaving  any  traces. 
If,  on  the  other  hand,  li^nng  tumour  cells  from  a  carcinoma  or  sarcoma, 
for  example,  are  inoculated  upon  animals,  they  go  on  developing,  and 


§  127.]  GROWTH,  COURSE,  DIAGNOSIS,  TREATMEN'T  OF  TUMOURS.     Y75 

give  rise  to  tumours  which,  are  the  same  as  the  original  one.  Man 
also  may  become  infected  with  the  .germs  of  tumours,  and  this  has 
occurred  during  operations  for  their  extirpation.  Carcinoma  and  sar- 
coma are  the  typical  malignant  tumours  ;  they  lead  to  local  destruction 
of  tissue  and  to  general  infection  of  the  body  by  the  formation  of 
metastases.  They  are  especially  the  ones  which  so  commonly  reappear 
.at  the  original  site  after  they  have  been  extirpated.  These  recurrences 
are,  according  to  Thiersch,  due  partly  to  tumour  germs  which  were  not 
removed,  though  in  other  instances  we  have  to  deal  with  a  new  tumour 
similar  to  the  one  that  was  removed,  which  makes  its  appearance  in  the 
cicatrix  or  near  by,  months  or  even  years  afterwards.  Then,  again, 
recurrences  may  be  due  to  the  inoculation  at  some  point  of  living 
tumour  cells  during  the  extirpation  of  the  primary  tumour.  It  can 
easily  be  understood  that  a  benign  tumour  may  also  prove  fatal  to  the 
bearer  on  account  of  its  position,  as  exemplified  by  an  osteoma  on  the 
inner  table  of  the  skull. 

The  evil  efEects  of  tumours  upon  the  organism  are  partly  local  and 
partly  constitutional  in  character.  Those  in  particular  which  grow 
rapidly  are  a  great  drain  upon  the  system.  The  part  which  is  affected 
may  be  entirely  destroyed,  and  the  formation  of  metastases,  together 
with  the  necrosis  and  ulceration  undergone  by  the  tumour,  may  involve 
different  organs  and  eventually  lead  to  an  increasing  general  cachexia, 
to  which  the  patient  will  succumb.  This  cachexia,  manifesting  itself 
in  the  form  of  general  disturbances  of  nutrition,  loss  of  flesh,  and 
marasmus,  appears  in  malignant  tumours  which  are  accompanied  by 
local  destruction  of  tissue  and  metastases.  It  is  probably  caused 
mainly  by  poisons  which  are  formed  directly  by  the  malignant  tumours 
(see  also  page  823).  Rommelaire  and  Eanzier  have  found  that  the 
excretion  of  urea  is  diminished  in  all  malignant  tumours,  and  may 
ultimately  become  less  than  twelve  grammes  jpro  die.  The  degree  and 
rapidity  of  development  of  the  cachexia  depend  upon  the  location  of 
the  tumour,  its  condition  (ulceration,  necrosis,  haemorrhage),  and  the 
age  and  constitution  of  the  patient.  The  degree  of  malignancy  varies 
considerably.  Some  malignant  tumours,  like  epithelioma  of  the  lip  and 
the  flat  skin  cancer  {ulcus  rodeiis),  spread  but  slowly  to  the  nearest  lymj)h 
glands,  while  others — carcinomata  and  sarcomata,  for  instance — go  on 
very  rapidly  to  the  formation  of  metastases  in  internal  organs.  The 
above-mentioned  gradual  diminution  in  the  excretion  of  nitrogen, 
which  is  met  with  in  malignant  tumours,  may  occasionally  have  great 
value  in  determining  the  need  and  prognosis  of  surgical  interference, 
especially  if  the  decrease  in  the  amount  of  urea  is  marked,  in  which 
case  operative  procedures  are  contraindicated. 


770  TUMOURS. 

The  Possibility  of  curing  Malignant  Tumours  {Carcinoma  and 'Sar- 
coma). — A  variety  of  statements,  based  upon  statistics,  have  been  pub- 
lished relating  to  the  curabiHtv  of  the  mahgnant  tumours.  Fischer 
and  Meyer  have  written  an  especially  interesting  article  on  this  subject. 
Of  tvs^o  hundred  and  ninety-eight  cases  of  malignant  tumours  operated 
upon  by  Kose  in  the  hospital  at  Zurich  between  1867  and  1878,  Meyer 
was  able  to  get  reliable  returns  from  sixty-four.  Of  these  sixty-four, 
tweutv-two  were  alive  in  1887  without  recurrence,  and  showed  a  period 
of  exemption  varying  from  nine  years  and  seven  months  to  twenty 
years  and  three  months,  j^ineteen  died  without  recurrence,  the  period 
of  exemption  varying  from  one  and  a  half  to  sixteen  years.  In  the 
remaining  five  patients  the  cause  of  death  could  not  be  ascertained. 
Among  the  cases  of  cure  were  some  exceedingly  serious  ones,  involv- 
ing very  extensive  operations,  with  removal  of  recurrent  tumours  and 
diseased  lymphatic  glands.  Sarcoma,  cysto- sarcoma,  and  fibro-sarcoma 
showed  the  longest  period  of  exemption,  while  carcinoma  showed  the 
fewest  instances  of  permanent  cure.  In  rare  cases  of  sarcoma  of  the 
skin  and  multiple  melanosarcoma,  spontaneous  retrograde  changes 
have  been  observed  which  have  resulted  in  the  complete  and  pernia- 
nent  disappearance  of  the  tumours  (Hardaway,  author). 

Diagnosis  of  Tumours. — The  diagnosis  of  tumours  is  not  alwaj-s  easy. 
By  means  of  inspection,  palpation,  and  examination  of  the  subjective  symp- 
toms we  try  to  form  as  correct  an  idea  as  possible  of  the  location  and  struc- 
ture of  the  tumour.  The  location  of  a  neoplasm  often  enables  us  to  deter- 
mine its  nature.  Frequently  a  differential  diagnosis  must  be  made  between 
an  inflammatory  process  and  a  new  growth  (see  page  252,  Diagnosis  of  In- 
flammation). In  doubtful  cases  puncture  with  a  liypodermic  needle  may  be 
necessary.  It  is  important  to  determine  before  the  operation  whether  the 
tumour  is  benign  or  malignant,  in  order  to  decide  upon  the  kind  of  operation 
to  pursue.  In  suitable  cases— for  examjjle,  ip  growths  within  the  larynx 
probably  carcinomatous  in  nature — parts  of  the  tumour  are  removed  and 
examined  microscopically.  Syphilis,  tuberculosis,  and  other  chronic  infec- 
tious diseases  must  always»be  considered  in  making  a  differential  diagnosis, 
as  a  large  number  of  the  connective-tissue  tumours — such  as  certain  so-called 
sarcomata  of  muscle,  many  spindle-celled  sarcomata,  neuromata,  keloids,  and 
malignant  lymphomata  (Esmarch) — are  gummata,  and  can  be  cured  by  an 
antisyphilitic  treatment.  Some  tumours,  particularly  the  cystic  variety,  are 
translucent.  This  translucency  can  be  made  out  by  allowing  the  light  from 
an  electric  lamp,  for  instance,  to  pass  through  the  tumour. 

General  Treatment  of  Tumours. — The  general  rule  in  regard  to  the 
treatment  of  tumours — which  we  shall  later  discuss  more  fully  in 
speaking  of  the  individual  tumours — is  that  they  should  be  removed  as 
quickly  and  as  thoroughly  as  possible.  The  sooner  a  malignant 
tumour  is  radically  excised  the  better  is  the  prospect  of  a  complete  and 


§127.]  GKOWTH,  COURSE,  DIAGNOSIS,  TREATMENT  OF  TUMOURS.     777 

permanent  cure.  The  possibility  of  the  total  removal  of  a  tumour 
depends  upon  its  location  and  the  kind  of  organ  involved.  In  malig- 
nant tumours,  especially  carcinoma,  the  neighbouring  lymph  glands 
should  also  be  removed,  even  though  they  are  not  diseased,  and  after 
every  amputation  of  the  breast  for  carcinoma  the  lymphatic  glands 
and  surrounding  fat  in  the  axilla  must  likevs^ise  be  extirpated.  The 
removal  of  tumours  is  accomplished  usually  by  the  knife,  though  occa- 
sionally by  the  galvano-  or  thermo-cautery,  red-hot  iron,  ligature, 
ecrasement,  etc.,  methods  all  of  which  have  been  sufficiently  described 
in  §§  24^44. 

In  proper  cases  Pean  recommends  the  removal  of  the  tumour  in 
pieces  {morcellement).  The  method  consists  mainly  in  first  rendering 
the  tumour  as  bloodless  as  possible  by  the  use  of  differently  formed 
clamps  applied  around  its  circumference,  after  which  the  growth  is 
excised  in  portions,  and,  if  possible,  the  wound  is  sutured  while  the 
clamps  are  still  in  place.  The  latter  can  then  usually  be  taken  off  and 
the  wound  dressed.  In  other  cases  Pean  leaves  the  forceps  in  position 
for  twelve  to  forty-eight  hours.  An  almost  bloodless  operation  can 
thus  be  performed  even  in  the  case  of  very  vascular  tumours. 

The  encapsulated,  myelogenic,  giant-celled  sarcoma  of  bone  can  in 
suitable  cases  be  removed  by  cutting  away  only  the  anterior  half  of  the 
bony  capsule  by  means  of  the  chisel  and  hammer,  or  the  saw,  and  then 
carefully  scraping  out  the  tumour  mass  with  a  sharp  spoon.  ]^ussbaum 
has  lately  made  use  of  the  thermo-cautery  for  the  destruction  of  malig- 
nant tumours  like  cancers.  By  circumcision  with  the  thermo-cautery 
in  cases  of  inoperable,  malignant  neoplasms,  the  patient  can  be  helped 
very  materially ;  the  growth  of  the  tumours  is  thus  diminished,  the 
pain  caused  to  disappear,  and  any  carcinomatous  ulcerations  are  im- 
proved and  their  decomposition  checked.  In  cases  of  sloughing,  in- 
operable carcinomata,  the  removal  of  the  softened  portions  with  the 
sharp  spoon  and  the  subsequent  application  of  the  thermo-cautery  give 
good  results.  In  the  case  of  inoperable  ulcerating  carcinomata  and 
sarcomata,  the  use  of  different  caustics,  in  the  form  of  caustic  salves, 
for  example,  is  to  be  recommended. 

Many  attempts  have  been  made  to  destroy  tumours,  esjDCcially  in- 
operable sarcoma  and  carcinoma,  lymphoma  and  myoma,  by  means  of 
parenchymatous  injections  of  absolute  alcohol,  tincture  of  iodine, 
ergotine,  acetic  acid,  nitrate  of  silver,  arsenic,  turpentine,  osmic  acid, 
phosphorus,  etc.  Turpentine  is  injected  with  equal  parts  of  absolute 
alcohol,  or  one  part  of  turpentine  to  two  parts  of  alcohol,  from  a  half 
to  a  whole  hypodermic  syringeful  about  every  ten  to  fourteen  days. 
This  is  usually  followed  by  the  formation  of  abscesses  which  cause  a 


778  TUMOURS. 

variable  amount  of  shrinkage  in  the  size  of  the  tumour.  Three  drops 
of  a  one-per-cent.  solution  of  osmic  acid  are  injected  every  day.  Ar- 
senic can  be  given  in  the  form  of  Fowlers  solution,  either  internally 
or  subcutaneously.  Internally  one  begins  with  two  drops  daily,  and 
increases  the  dose  two  to  three  drops  every  third  day.  About  two 
drops  of  Fowler's  solution,  undiluted,  are  injected  into  the  tumour 
daily,  or  ten  drops  of  the  undiluted  solution  once  a  week.  The  solu- 
tion may  be  diluted  two  or  three  times  for  susceptible  patients.  A 
vio;orous  arsenic  treatment  is  to  be  recommended  in  the  case  of  inoper- 
able carcinomata,  and  particularly  sarcomata.  Mosetig-Moorhof  finds 
the  parenchymatous  injection  of  aniline  dyes  (pyoktannin,  methyl 
violet,  1  to  oUO)  very  useful  in  malignant  tumours  (carcinoma  and 
sarcoma),  but  the  success  which  he  has  reported  has  not  been  ex- 
perienced by  other  surgeons  (Billroth) ;  on  the  contrary,  Ijad  results, 
such  as  premature  softening,  breaking  through  of  the  skin,  slough- 
ing, etc.,  were  obtained.  In  cases  of  inoperable  tumours  erysipelas 
has  Ijeen  inoculated  by  means  of  cultures  of  the  erysipelas  coccus,  after 
Busch  had  observed  that,  as  a  result  of  erysipelatous  inflammation, 
tumours,  such  as  sarcoma  of  the  face  or  neck,  disappeared  by  fatty 
degeneration.  Janicke  and  Xeisser  were  able  to  demonstrate  by 
microscopic  examination,  in  a  case  of  carcinoma  with  fatal  erysipelas 
due  to  inoculation,  that  the  cancer  cells  are  actually  destroyed  by  the 
erysipelas  cocci.  One  should,  however,  take  into  account  that  such  an 
inoculation  may  cause  death,  and  hence  one  should  warn  the  patient 
of  the  danger  of  the  treatment.  For  a  description  of  Emmerich's  ery- 
sipelas serum  in  connection  with  malignant  tumours,  see  page  82-4.  A 
number  of  cases  have  been  reported  in  which  there  has  been  improve- 
ment— usually  a  temporary  one  only — after  the  use  of  this  serum 
(diminution  in  the  size  of  the  tumour,  cessation  of  the  pain,  improve- 
ment in  the  general  condition,  etc.).  Coley  employs  for  sarcoma  a 
mixture  of  the  toxines  of  the  streptococcus  and  Bacillus  ])vodigiosu8^ 
which  he  injects  into  the  tumour  and  into  other  parts  of  the  body. 
The  cultures  are  made  in  the  same  nutritive  medium  (l)ouillon) ;  the 
Bacillus  prodigiosus  is  added  ten  days  later,  and  then  in  ten  days  more 
the  combined  culture  is  sterilised  by  heating  it  to  a  temperature  of 
58.6°  C.  Coley  employs  filtered  cultures  only  in  children  and  weakly 
individuals ;  they  are  from  ten  to  fifteen  times  weaker  than  the  unfil- 
tered.  He  begins  with  the  injection  of  0.32  cubic  centimetres.  The 
action  of  the  toxines  upon  malignant  tumours,  particularly  sarcomata, 
is  said  to  consist  in  progressive  coagulation  necrosis,  with  fatty  degen- 
eration. The  method  is  only  dangerous  in  case  too  large  doses  are 
used  or  the  asepsis  is  faulty.     Out  of  two  hundred  cases  Coley  lost 


§  128.]  THE  DIFFERENT   VARIETIES   OF   TUMOURS.  779 

two  in  consequence  of  the  treatment.  This  form  of  treatment  should 
only  be  used  in  inoperable  malignant  tumours,  and  perhaps  after  the 
first  operation,  for  the  prevention  of  recurrences.  Sarcomata,  particu- 
larly of  the  spindle-celled  variety,  react  best  to  the  treatment ;  while 
in  carcinomata  no  improvement  was  found  to  take  place.  Coley's 
method  has  been  used  by  Bruns,  Czerny,  Eichet,  Fedorow,  the  author, 
and  others,  usually  witli  negative  results.  Coley  has  reported  on  one 
hundred  and  forty  cases  of  inoperable  sarcomata  which  were  treated 
by  himself  and  others :  out  of  eighty -four  round-celled  sarcomata, 
three  were  cured  (period  of  cure  one  to  three  years) ;  out  of  twenty - 
one  spindle-celled  sarcomata,  ten  disappeared  entirely,  and  in  three 
cases  a  recurrence  took  place  after  nine  months  to  a  year  and  a  half. 
Melauomata  were  not  cured.  Peterson  has  reported  the  results  in 
Czerny's  clinic :  out  of  twenty-seven  cases  (ten  carcinomata  and 
seventeen  sarcomata)  which  were  treated  with  Coley's  serum,  and 
seven  carcinomata  treated  with  the  serum  of  Emmerich  and  Scholl, 
a  marked  degeneration  of  the  tumour  occurred  in  one  case  only  (a  sar- 
coma of  the  parotid).  This  tumour  had  been  regarded  as  inoperable, 
but  subsequently  the  portion  that  was  left  could  be  easily  extirpated. 
In  the  other  cases  Czerny,  like  myself,  observed  only  a  temporary  and 
partial  softening  in  consequence  of  fatty  degeneration  of  the  cells, 
with  oedematous  infiltration  of  the  tumour.  In  some  cases  the  pain 
became  less,  the  ulceration  diminished,  etc.  Occasionally  the  breaking 
down  in  the  central  portion  of  the  tumour  is  accompanied  by  increased 
growth  at  the  periphery.  The  effects  of  the  toxines  upon  the  general 
system  are  sometimes  dangerous ;  the  cultures  of  the  Bacillus  jjro- 
digiosus  have  a  deleterious  effect  upon  the  heart,  and  those  of  the 
streptococcus  sometimes  cause  irritation  of  the  kidneys.  In  a  number 
of  cases  I  observed  high  fever  and  marked  emaciation.  Eichet  and 
Hericourt  have  injected  serum  from  animals  inoculated  with  fluid 
obtained  from  sarcoma  or  carcinoma,  and  also  serum  from  uninoculated 
animals  which  did  not  have  as  toxic  an  action.  Both  kinds  of  serum 
were  found  to  cause  only  a  diminution  in  the  size  of  the  tumours. 

The  man  who  succeeds  in  discovering  a  really  successful  method  of 
treating  malignant  tumours — carcinomata,  for  example — would  deserve 
to  be  honoured  by  humanity  for  all  time  as  being  its  greatest  bene- 
factor. 

§  128.  The  Different  Varieties  of  Tumours.  Connective-tissue  Tu- 
mours I  Fihroma. — Of  the  different  varieties  of  connective -tissue 
tumours,  we  shall  first  take  up  the  fibroma,  which  is  made  up  almost 
entirely  of  this  kind  of  tissue.  We  distinguish  ordinarily  a  hard  (Fig. 
46Y)  and  a  soft  (Figs.  468,  469)  form.     The  hard  fibroma  is  made  up. 


^80 


TUMOURS. 


Fig.  467. — Hard  fibroma  of 
the  skin  of  the  nose  (^Bill- 
roth). 


as  a  rule,  of  bundles  of  tough,  coarse  fibres  with  few  cells,  while  the 
soft  form  consists  of  loose  connective  tissue  having  a  great  number  of 
cells.  There  are,  of  course,  numerous  transition  forms.  The  soft 
fibroma  (fibroma  molle)  is  also  called  fibroma 
molluscum  (Figs.  4:68,  469,  470).  The  vascu- 
larity of  the  fibromata  varies  greatly,  being 
sometimes  very  slight,  and  again  so  marked  as 
to  give  rise  to  large  dilatations  of  the  blood  and 
lymph  vessels,  as  in  the  diffuse  hyperplasia  of 
tissue  found  in  elephantiasis.  Fibroma  mol- 
luscum must  not  be  confounded  vritli  the  so- 
called  molluscum  contagiosura  (see  page  809). 

The  retrograde  changes  that  take  place  in 
fibromata  are  fatty  degeneration,  calcification, 
softening,  the  formation  of  cavities  and  cysts, 
and  a  perforation  of  the  skin  with  the  forma- 
tion of  ulcers  as  a  result  of  long-continued  traumatic  irritation  from 
without,  and  of  inflammation  leading  to  the  formation  of  abscesses. 
The  fibroma  only  becomes  dangerous  from  its  location  and  size,  the 
latter  being  sometimes  very  great,  particularly  in  the  case  of  fibroma 
of  the  skin  or  uterus  (Fig.  470).  In  other  respects  the  fibroma  is  a 
perfectly  benign  neoplasm,  giving  rise  to  no  metastases,  although  it  is 
found  multiple,  especially  in  the  skin, 
where  it  may  appear  in  vast  numbers. 
The  multiple  fibromata  of  the  skin  (Fig. 
470)  may  be  the  size  of  a  pea  or  wal- 
nut, or  they  may  grow  and  form  veiy 
large  soft  tumours  ;  they  are  sometimes 
accompanied  by  disturbances  of  the  gen- 
eral nutrition  (so-called  leontiasis,  Yir- 
chow).  I  cannot  discuss  here  the  ques- 
tion (see  §  S5)  whether  in  such  cases  we 
do  not  really  have  to  do  with  leprosy. 
According  to  the  investigations  of  Reck- 
linghausen, the  multiple  soft  fibromata 
of  the  skin  develop  particularly  from 
the  connective-tissue  sheaths  of  the  seba- 
ceous glands,  vessels,  and  nerves  (neuro- 
fibroma). Many  soft  fibromata  are  dif- 
fuse, hyperplastic  formations,  and  represent  a  transition  to  elephantiasis, 
as  seen  in  Fis:.  468.  These  formations  are  sometimes  called  cutis  pen- 
dula  or  elephantiasis  of  the  skin.     There  are  also  observed  in  some 


Fio.  46S. — Soft  fibroma  of  the  face 
(elephantiasis  faciei)  of  a  twenty- 
fom'-year-old  woman  (Schuller, 
Griefswald  clinic). 


128.] 


THE   DIFFERENT   VARIETIES   OF   TUMOURS. 


781 


cases  pigmentations  which  take  the  form  of  congenital  moles,  or  of 
brown  discolorations  with  a  growth  of  hairs  (see  Angeioma,  page  790). 
Many  of  the  soft  fibromata  are  transition  forms  of  angeiomata,  cayern- 
omata,  and  Ijmphangeiomata.  Just  as  in  the  skin,  there  are  also 
fomid  in  the  internal  organs  diffuse  fibromata,  which  in  these  struc- 
tures likewise  develop  from  the  connective-tissue  sheaths,  especially  of 
the  glandular  ducts  and  vessels ;  among  these  is  the  intercanicular 
fibroma  of  the  mammary  gland. 

Keloid. — In  speaking  of  the  hard  fibromata,  mention   should  be 
made  of  the  keloid,  i.  e.,  a  tumour-like,  fibrous  degeneration  of  the 


Fig.  469. — Soft  fibroma  of  the  right  arm  and  chest  in  a  man  forty  years  of  age 
(Byrom  Bramwell). 

skin  and  subcutaneous  tissue  in  the  form  of  a  tough  swelling  which 
sends  out  cord-like  processes  into  the  healthy  surrounding  parts.  In 
by  far  the  majority  of  cases  the  keloid  develops  within  a  cicatrix 
(cicatricial  keloid).  We  distinguish,  as  do  Warren,  Kaposi,  Deneriaz, 
and  others,  three  forms  of  keloid  :  (1)  a  spontaneous,  (2)  a  cicatricial 
keloid,  and  (3)  the  hypertrophied  cicatrix.  Scrofulous,  tubercular,  and 
syphilitic  individuals  seem  especially  prone  to  keloid.  Deneriaz  is  dis- 
posed to  think  that  keloid  is  caused  by  infection  with  microbes.  It  is 
characteristic  of  keloid  to  recur  almost  invariably  after  extirpation. 
Leloir  and  Yidal  recommend,  in  true  keloid,  multiple  scarifications, 
which  should  be  made  in  different  directions  during  several  sittings. 


iS2 


TUMOURS. 


and  followed  hy  the  application  of  a  moist  dressing  with  compresses 
wet  in  boric-acid  solution,  and  on  the  next  day  of  a  mercurial  plaster. 

Marie  reports  good  results 
from  the  injection  of  20 
per  cent,  creosote  oil. 

Fibromata  are  most 
commonly  found  in  the 
skin  and  subcutaneous  tis- 
sue, in  the  nerves,  perios- 
teum, bone,  uterus,  and 
ovaries.  Some  of  the  pol- 
yps which  form  in  the 
facial  cavities — many  na- 
sal polyps,  for  example — 
are  periosteal  fibromata. 
There  are  sometimes  seen, 
especially  in  the  pharynx, 
polyps  which  are  covered 
with  hair  and  possess  an 
epidermis,  rete  Malpighii, 
and  corium,  and,  accord- 
ing to  Arnold,  originate 
from  strayed  embryonic 
cells.  They  belong,  prob- 
ably, to  the  teratomata  (see  page  828).  Combination  or  mixed  fibrous 
tumours  include  fibro-myxoma,  fibro-myoma,  fibro-sarcoma,  fibro- 
neuroma,  fibro-angeioma,  fibro-cavernoma,  fibro-lympliangeioma. 

The  diagnosis  of  fibroma  can  be  easily  made  from  what  we  have 
stated  in  describing  the  neoplasm. 

Treatment  of  Fibroma. — The  treatment  of  a  fibroma  consists  in  its 
removal  by  the  knife,  the  galvano-cautery,  or  the  thermo-cautery. 
Large  diffuse  fibromata  of  the  skin  are  to  be  extirpated  in  several  sit- 
tings by  cuneiform  excisions  followed  by  deep  sutures.  Billroth  once 
removed  a  large  tumour  in  twenty  sittings.  I  removed  an  extensive 
diffuse  fibroma  involving  almost  the  entire  scalp  in  one  sitting,  and 
covered  the  surface  of  the  wound  with  Thiersch  skin  grafts.  In  cases 
of  ver}^  large  fibromata  of  the  uterus  one  must  often  give  up  all  idea 
of  extirpation,  and  use  injections  of  ergotine,  or,  in  order  to  stop  the 
frequent  haemorrhages,  remove  both  ovaries  (Hegai").  The  description 
of  operations  for  fibroma  of  the  uterus,  etc.,  is  found  in  the  Regional 
Surgery. 

Fibromata  of  nerves  can  usually  be  removed  and  the  continuit_y  of 


Fig.  470. — Multiple  soft  fibromata  of  the  skiu  (fibroma 
molluscum  multiplex,  Virchow)  occurring  ou  a  forty- 
seveo-year-old  woman  (Virchow). 


§  128.]  THE   DIFFERENT  VARIETIES   OF   TUMOURS.  783 

the  nerve  preserved  (see  iS^euroma).  If  the  nerve  cannot  be  saved,  the 
nerve  stumps  can  sometimes  be  united  after  the  extirpation  of  the 
tumour  by  suture,  or  bj  the  use  of  the  neuroplastic  methods  described 
on  pages  484-487. 

Myxoma. — The  myxoma  is  made  up  of  a  soft,  gelatinous  tissue. 
The  microscopic  examination  shows  the  presence  of  a  mucoid  ground 
substance  with  a  fibrillar  framework  and  round,  spindle-shaped  or  star- 
shaped  cells.  The  latter  have  usually  many  branches  and  processes 
which  interlace  with  one  another  (Fig.  471).  Koster  has  denied  that 
the  myxoma  is  a  special  form  of  tumour,  and,  as  a  matter  of  fact,  it  is 
possible  to  look  upon  it  as  in  the  main  a  softened,  oedematous  fibroma 
or  lipoma  (myxo-fibroma,  myxo-lipoma).  Myxomatous,  softened  areas 
are  often  found  in  cartilaginous  tumours. 

The  myxomata  are  met  with  most  commonly  in  the  skin  and  sub- 
cutaneous tissue,  in  the  periosteum,  medulla  of  bone,  fasciae,  muscular 
sheaths,  nerves,  and  in  the  brain  and  its  coverings.  The  myxoma  is, 
generally  speaking,  a  benign  tumour,  but  metastases  and  transitions  to 
sarcoma  do  occur.     They  sometimes  attain  a  very  large  size. 

The  treatment  of  a  myxoma  consists  in  its  removal  according  to 
the  above  rules. 

Lipoma. — The  lipoma  (fatty  tumour)  is  a  lobulated  tumour  made  up 
of  fatty  tissue,  sometimes  soft  and  sometimes  firm  in  consistence.     The 
lipomata  are  either  circumscribed  or  diffuse  growths,  and  frequently 
possess   a   pedicle.     According 
to    their    location,    there    may 
be  distinguished  cutaneous  and 
subcutaneous,    subserous    (sub- 
peritoneal), subsynovial,  submu- 
cous, and   inter-    or  intramus- 
cular (subfascial,  peritendinous) 
lipomata.     The  lobes  of  fat  of       '  -    ^^-'  '       _^  -  ^" '' 

which  the  lipoma  is  made  up         .    ---'"^     ^-—^^-^        ~    "    ^^?^ 
are   usually   held    together   by  /         '\  "^.^        '^ — r:r  ^ 

bands  of  connective  tissue.     In- 

,  Fig.  471. — Cells  from  a  myxoma  of  the  cervical 

creased     development    of    the  fascia,    x  350. 

stroma  gives  rise  to  the  lipoma 

fibrosum.  In  some  instances,  especially  in  the  region  of  the  neck  and 
shoulder,  very  diffuse  lipomata  are  found.  Growth  of  the  fatty  vilh 
in  the  joints,  of  which  the  knee  is  a  prominent  example,  gives  rise  to 
the  lipoma  arborescens.  Similar  diffuse  lipomata  are  found  on  the 
tendon  sheaths.  The  articular  lipomata  probably  develop  as  a  result 
of  traumatic  ruptures  of  the  synovial  membrane,  causing  a  prolapse  of 


T84 


TUMOURS. 


the  retrosvnovial  fat  into  the  joint ;  they  are  also  encountered  in  ar- 
thritis deformans,  chronic  rhenniatisni,  syphilitic  arthritis,  etc.  The 
lipoma  arborescens  of  joints  sometimes  forms  a  transition  to  fibroma 

arborescens  (Sokoloff).  The  subperi- 
toneal and  submucous  lipomata  which 
develop  upon  the  stomach  and  intes- 
tine are  of  special  clinical  importance. 
The  lipomata  of  the  intestine  occasion- 
ally give  rise  to  intestinal  obstruction. 
According  to  Sutton,  two  forms  of 
lipoma  are  found  attached  to  the  spinal 
cord.  In  most  cases  they  are  the  re- 
sult of  the  change  of  the  sac  of  a  spina 
bifida  into  fatty  tissue  ;  less  frequently 
they  are  intradural  lipomata  which 
grow  around  the  spinal  cord.  The 
lipomata,  as  we  remarked  before,  some- 
times change  into  fibromata,  myxom- 
ata,  sarcomata,  and  cavernous  tumours. 
They  may  attain  an  enormous  size, 
especially  when  situated  on  the  back, 
and  o;rowths  of  this  kind,  weijjhinff 
twenty  to  forty  pounds,  have  been  suc- 
cessfully removed  (Billroth,  Hahn,  and 
others).  Pick  published  an  account  of 
a  subserous  lipoma  of  the  abdomen 
weighing  twenty -nine  pounds.  The 
lipoma  is  a  benign  tumour,  and  does 
not  give  rise  to  metastases,  though  it 
is  sometimes  multiple.  As  many  as 
thirty  to  forty  lipomata  have  been  observed  on  different  parts  of  the 
body,  particularly  in  fat  individuals.  They  are  most  likely  to  develop 
in  individuals  from  thirty  to  fifty  years  of  age,  but  are  sometimes 
congenital,  in  which  case  they  are  usually  diffuse,  often  combined  with 
telangeiectases,  dermoid  cysts,  and  fibromata,  and  occur  principally  in 
the  lumbar  region  and  on  the  buttocks.  The  so-called  "  false  tail "  is 
merely  a  congenital  lipoma  pendulum  which  is  situated  above  the  anus, 
and  may  occasionally  be  combined  with  sjDina  bifida  (Bartels). 

Quite  recently  Groscli  has  published  the  results  of  very  exhaustive  studies 
on  this  tumour,  which  place  the  seemingly  simple  lipomata  in  a  new  light. 
He  has  attempted  to  show  that  certain  tumours  are  prone  to  develop  upon 
particular  parts  of  the  body,  mainly  on  account  of  definite  anatomical  condi- 


FiG.  47 i. — Lipoma  of  the  back,  "weighing 
tifty-six  pounds,  in  a  man  sixty-one 
years  of  age.  Excision,  followed  l:)y 
death  from  sepsis  some  days  after  the 
operation. 


§  128.]  THE   DIFFERENT    VARIETIES   OF   TUMOURS.  Y85 

tions  and  sti'uctural  peculiarities  wliich  these  parts  possess.  The  lipomata 
appear  to  have  a  specially  marked  tendency  to  grow  in  certain  localities, 
being  most  common  on  the  front  and  back  of  the  neck,  on  the  jjosterior 
aspect  of  the  trunk,  about  the  shoulder,  and  on  the  upper  and  lower  extremi- 
ties. They  are  seldom  encountered  on  the  head,  and  then  more  often  on  the 
face  than  on  the  scalp,  being  rarest  in  the  latter  region  (Konig,  Gussen- 
bauerj.  Grosch  states  that  they  occur  most  commonly  in  the  integument  of 
those  parts  of  the  body  which  have  a  scanty  covering  of  hair  and  a  small 
number  of  sweat  and  sebaceous  glands.  These  glands  eliminate  fats  and  their 
derivatives  in  addition  to  disintegrated  products  of  metabolism,  and  hence 
the  amount  of  their  secretion  is  an  important  index  of  the  amount  of  the 
subcutaneous  fat.  Obesity  and  lipoma  formation  are,  according  to  Grosch, 
quite  identical.  In  many  cases,  particularly  in  thin  individuals,  the  lipom- 
ata are  neuropathic  in  nature,  and  possibly  are  the  result  of  a  diminution 
in  the  secretion  of  the  sebaceous  and  sweat  glands  due  to  disturbances  in 
the  central  nervous  system.  Symmetrical  lipomata,  in  particular,  result 
in  this  way. 

The  diagnosis  of  a  lipoma  is  made  chiefly  from  its  soft,  movable, 
lobulated  character.  If  pressure  is  exerted  upon  the  tumour,  as  a  rule 
there  will  be  felt  a  distinct  crepitation  caused  by  the  crushing  of  single 
lobes  of  fat.  The  skin  over  the  lipoma  shows  little  shallow  depressions 
which  are  particularly  plain  when  the  tumour  is  encircled  by  the  hand. 

The  extirpation  of  lipomata  by  the  knife  and  scissors  is  very  easy 
even  in  the  case  of  large  tumours.  In  the  case  of  large  pedunculated 
lipomata  it  may  be  advisable  to  tie  rubber  tubing  about  the  pedicle 
or  apply  a  clamp  for  the 

purpose    of    arresting   the         ^_    ,  n  „  =_  '^^  ^  ^'~^ '^  ^^(-^  \ 

lieemorrhage    more   efEect-  V.'r.';    -  i  1  f'/?  T  "^*'^"^-"'  _  — 

ually.  i  "'  ^"  °   :    :  "   -    »  ^^    >,  ^ 

Chondroma   or   Enchon-  -'  i     i         ;  '  > -=.  A^V""    *  ^A^^ 

droma.  —  The    chondroma         ''^/=\   ,'   '  ' '^  ^-^.^V*^  ll,?' ^fe. 

consists  essentially  of  car-       ^,  •  -';'"'-    ^  1  "^  "      *-     "^  II    -  ' 

tilage,  most  commonly  hya-       li/  -_  _' :  °   '    '  '  *^  '"-»?'*  "^      "*  *''^  "'^ 

line,  less  often  fibrous  or       t-  ;-'      ;   ;  '  ■  '  -  ^-,^    iV~^  ^a  ^*^ 

reticular.     The  cells  which        '"  '^  -^  5  i  -^  'J  '''5A2=^^-^7>|i/  \ 

this  kind  of  tumour  con-  Fig.  473.— Small-celled  Fig.  474.— Large-celled  chon- 
.    .  T  -,,     ,~f-^.  chondroma    of   the  droma  of  the  pelvis  very 

tams   may  be   small  (I  ig.         finger,    x  so.  rich  in  cells.    $  so. 

473)  or  large  (Fig.  4Y4), 

and  their  quantity  varies  within  wide  limits.  The  enehondromata  are 
most  often  encountered  in  places  where  cartilage  normally  exists — 
hence,  upon  the  skeleton  (epiphyses,  periosteum,  medulla  of  bones) — 
though  they  are  also  met  with  in  the  parotid  and  thyroid  glands, 
mamma,  and  testicle.  The  enehondromata  of  the  skin  and  internal 
organs  develop  partly  from  stray  cartilage  cells  and  partly  from  trans- 
53 


7S6 


TUMOURS. 


formed  connective-tissue  cells,  especially  the  endothelia  of  the  connec- 
tive-tissue sheaths  and  of  the  blood  and  lymph  vessels.  Thus  chondro- 
endotheliomata  are  sometimes  seen.  The  enchondromata  which  grow 
directly  from  cartilage — that  of  the  epiphyseal  line,  for  example — are 
also  called  ecchondroses.  Like  the  exostoses,  the  enchondromata  are 
often  multiple,  and  appear  in  great  numbers.  Yery  remarkal)le  cases 
of  multiple  enchondromata  of  different  bones,  combined  with  venous 
angeiomata  of  the  soft  parts,  have  been  described  by  Kast,  Reckling- 
hausen, and  others.  Probably  both  kinds  of  tumours  were  the  result 
of  disturbances  of  circulation  or  of  an  abnormal  congenital  displace- 
ment of  tissue  cells.  The  angeioma  formation  might,  however,  be  a 
secondary  manifestation.  Enchondromata  are  comparatively  often  the 
seat  of  degenerative  changes,  such  as  myxomatous  softening  and  cyst 
formation.  The  most  important  mixed  forms  of  chondroma  are  the 
osteochondroma  and  chondrosarcoma.  Chondromata  may  eventually 
become  entirely  ossified.  I  have  also  seen  a  chondroma  combined  with 
a  melanosarcoma — on  the  hand,  for  example.  The  simple  enchondroma 
is  in  general  a  benign  neoplasm,  but  malignant  forms  with  metastases 
do  occur.  It  is  most  often  found  in  young  subjects.  The  tumours 
attain  at  times  a  very  considerable  size,  especially  when  situated  upon 
the  pelvis  or  the  femur.  A  favourite  locality 
for  enchondromata  is  the  fingers,  where  they 
form  characteristic  nodular  tumours  (see  Fisr. 
475).  They  may  also  originate  from  cartilage 
cells  in  the  ethmoid  bone,  and  grow  as  an 
osteochondroma  or  cartilaginous  exostosis  into 
the  frontal  sinus  and  nasal  cavity.  These 
osteochondromata  or  exostoses  of  the  frontal 
sinuses  and  nasal  cavity  can  become  detached, 
and  are  then  found  in  these  cavities  in  the 
form  of  fi-ee  bodies  or  dead  osteochondromata 
or  osteomata.  I  have  published  a  typical  case  of 
this  kind.  The  frequency  with  which  enchon- 
dromata or  ossified  chondromata  (exostoses)  of 
the  ethmoid  bone  occur  can  be  explained  by  the 
fact  that  remnants  of  the  cartilaginous  cranium 
remain  in  this  locality  for  a  comparatively  long 
time.  Degenerative  changes — i.  e.,  cystic  soft- 
ening of  enchondromata — sometimes  give  rise 
to  chondrocystomata,  chondrofibrocystomata  or  osteocystomata,  which 
resemble  sarcomata  somewhat  clinically,  but  are  usually  perfectly  benign 
and  can  be  completely  cured  by  extirpation  (see  page  788). 


Fig.  475. — Enchondroma  of  the 
fingers  of  the  left  hand  of 
a  twenty-year-old  spinner 
(Leo). 


128.] 


THE   DIFFERENT   VARIETIES   OF   TUMOURS. 


Y87 


Fig.  476.— Exostosis  of  the  femur  .  Buscli). 


The  location  and  the  hard  nodular  consistency  of  the  tumours  are 
important  factors  in  making  the  diagnosis.  The  treatment  consists  in 
their  prompt  removal  with  the  hammer  and  chisel. 

Osteoma. — The  osteoma  is  a  tumour  made  up  of  bone,  and  occurs 
not  only  upon  the  skeleton,  but  also  in  the  skin,  muscles,  tendons, 
lungs,  parotid  gland,  and  brain.  We  have  already  spoken  of  diifuse 
and  circumscribed  osteomata  —  the 
hyperostoses  and  osteophytes  —  in 
connection  with  inflammations  of 
bone  (see  page  644),  and  of  the  so- 
called  "riding  "  or  "  exercise  "  bones 
which  develop  in  the  muscles  (see 
page  571),  and  of  the  diifuse  forma- 
tion of  bone  which  takes  place  in 
myositis  ossificans  progressiva  (see 
page  572).  The  develojDment  of  bone 
in  tissues  where  bone  is  normally  not 
present  is  caused  by  cells  of  carti- 
lage, periosteum,  or  marrow,  which  have  strayed  during  foetal  life  or 
have  become  separated  by  traumatism.  Osteomata  also  frequently 
appear  upon  bones  after  fractures.  I  once  successfully  removed  such 
a  one,  almost  as  large  as  a  fist,  from  the  horizontal  and  descending 
ramus  of  the  pubic  bone,  where  it  had  followed  a  fracture.  31.  Lange 
has  reported  an  interesting  case  of  multiple  exostosis  formation  caused 
by  an  ossifying  myositis  due  to  multiple  fractures  of  both  femurs  and 
of  the  pelvis  (see  page  607,  Fig.  403). 

The  osteomata  situated  on  the  surface  of  bones  are  also  called  exos- 
toses (Fig.  476),  and  those  in  the  interior  of  bones  enostoses.  The  exos- 
toses which  are  developed  in  the  periosteum  are  sometimes  very  mov- 
able, and  do  not  have  a  direct  connection  with  the  bone.  Their  struc- 
ture is  in  some  cases  as  compact  as  ivory  (osteoma  eburneumj,  and  in 
other  cases  spongy  (osteoma  spongiosum).  Many  osteomata  have  a 
covering  of  cartilage  (exostosis  cartilaginea),  and  this  is  especially  tnie 
of  the  exostoses  in  the  neighbourhood  of  the  epiphyseal  cartilage,  which 
are  really  ossified  enchondromata  or  ecchondroses  (ecchondrosis  ossifi- 
cans). The  cartilaginous  exostoses  (osteomata  with  a  covering  of  hya- 
line cartilage)  are  sometimes  styloid  or  finger-shaped,  and  resemble  a 
metacarpal  or  metatarsal  bone.  These  cartilaginous  exostoses,  or  rather 
ossified  chondromata,  are  often  multiple,  occurring  in  the  neighbour- 
hood of  the  epiphyses  of  many  different  bones  in  the  same  individual. 
Occasionally  the  influence  of  heredity  is  very  noticeable.  Heymann 
observed  multiple  cartilaginous  exostoses  on  many  of  the  bones  of  a 


788  TUMOURS. 

pLtliisical  patient  ^vhose  mother  and  four  brothers,  as  well  as  his  three 
children,  all  had  a  similar  peculiarity.  lieinecke  collected  thirty-six 
cases  of  multiple  exostoses  from  literature,  in  which  the  hereditary  pre- 
disposition could  be  traced  back  in  one  case  five  generations,  in  fifteen 
cases  three  generations,  and  in  twelve  cases  two  generations.  In  such 
instances  the  development  of  the  exostoses  is  due  to  an  inherited  pre- 
disposition, and  begins  usually  in  the  third  or  fourth  year  of  life.  In 
rare  cases  these  multiple  cartilaginous  exostoses  that  are  found  on  dif- 
ferent -parU  of  the  body  disajjpear  gradually  of  themselves,  while  others 
remain  unchanged  (Hartmann). 

By  e.costosis  hiirsata  is  meant  an  exostosis  which  is  covered  by  a 
bursa.  It  develops  principally  in  the  joints,  from  the  articular  carti- 
lage, and  pushes  the  synovial  membrane  before  it.  The  pocket  thus 
made  in  the  capsule  of  the  joint  either  remains  open,  so  that  the  bursa 
retains  its  connection  with  the  joint,  or  it  becomes  entirely  cut  off  from 
the  latter  (see  page  Y18).  These  bursal  or  synovial  exostoses  generally 
contain  a  fluid  resembling  synovia,  and  several  free-joint  bodies  usually 
made  up  of  hyaline  cartilage.  This  form  of  exostosis  may  also  occur  at 
some  distance  from  a  joint,  and  even  ujDon  the  bones  of  the  trunk  and 
ribs ;  in  these  cases  the  enveloping  sac  forms  after  the  fashion  of  an 
accessory,  mucous  bursa.  The  exostoses  can  become  gradually  or  sud- 
denly detached  by  traumatisms,  for  example,  and  then  persist  as  dead 
pieces  of  bone,  like  the  free  dead  osteomata  in  the  frontal  sinuses  and 
nasal  cavity. 

Osteomata  of  the  teeth  and  alveolar  processes  are  comparatively 
common.     The  tumours  of  the  teeth,  the  so-called  odontomata,  which 

consist  of  dentine  and  enamel,  arise  from 
the  pulp  or  degenerated  embryonic  tooth 
cells  as  a  result  of  anomalies  during  the 
l^eriod  of  development  of  the  teeth,  and 
sometimes  in  young  subjects  after  inju- 
ries. The  true  odontomata  are  rare,  and 
are  found,  according  to  Heath,  almost 
exclusively  on  the  lower  jaw.  They  are 
sometimes  formed  from  strayed  dental 
Fig.  477.— Osteosiircuiiia  i  osteoid,  ma-     gcrms,  and  can  then  develop  in  a  large 

Sua  (BSr  "'  '^'  '''^''"°'     ^^^^y  ^^^^*:^'  "^  *^^^  necrosis  of  the  bone 

with  an  inclosed  sequestrum  is  suspected 
(Krogius ).  Metnitz  has  published  an  account  of  five  cases  of  this  rare 
form  of  tumour,  and  thinks  that  want  of  room,  abnormal  position  of 
the  neighbouring  teeth,  and  inflammatory  processes,  especially  chronic 
periostitis,  are  important  factors  in  their  etiology.     In  general,  two 


§  128.] 


THE  DIFFERENT   VARIETIES   OF   TUMOURS. 


789 


Fig.  478. — Congeni*:al  telangiecta- 
sis (birth -mark J  -nitli"  hairs 
(Mason). 


forms  of  odontoma  can  be  distinguished — soft  and  hard — or,  Ijetter, 
'those  with  dentine  and  those  without  (Partsch).  The  exostoses  which 
form  on  teeth  are,  of  course,  not  to  be  counted  among  the  odontomata, 
but  among  the  osteomata. 

The  osteomata  are,  on  the  whole,  benign  tumours,  and  usually  grow 
slowlv,  but  sometimes  are  found  multiple,  occurring,  for  example,  on 
numerous  epiphyses,  where  they  are  ca- 
pable of  causing  disturbances  of  growth. 
In  cases  of  multiple  exostoses  of  the  bones 
of  the  cranium  and  face,  atrophy  of  the 
latter  has  been  observed  as  a  result  of  in- 
terference with  its  development.  The  ma- 
lignant osteomata  include  the  osteosarcoma, 
also  called  osteoids  (see  Fig.  -iTT),  which 
give  rise  to  extensive  local  destruction  of 
tissue  and  to  metastases  (see  sarcoma).  In 
this  category  belongs  also  the  very  vascu- 
lar (pulsating)  osteosarcoma.  For  cysts  of 
bone,  see  page  825, 

Pointed  exostoses  can  sometimes  cause 
injuries  to  large  arteries  and  veins,  and 
thus  lead  to  the  formation  of  aneurisms,  as  in  the  instances  observed 
by  Boling,  Kiister,  and  others.  In  Klister's  case  a  pointed  osteophyte 
wounded  the  popliteal  artery  and  led  to  the  formation  of  an  aneurism. 
After  removal  of  the  osteophyte  by  a  chisel,  and  double  ligation  of 
the  popliteal  artery,  a  rapid  recovery  was  made.  Kronlein  observed, 
on  the  other  hand,  that  a  traumatic  aneurism  of  the  popliteal  artery 
which  had  lasted  ten  years  caused  an  erosion  and  formation  of  osteo- 
phytes on  the  lower  end  of  the  femur. 

The  diagnosis  of  osteomata  can  usually  be  made  from  their  location 
and  hard,  bony  consistence. 

Osteomata  are  usually  removed  by  the  chisel  or  saw,  or,  when  in  the 
soft  parts,  by  extirpation  with  the  knife.  In  cases  of  exostoses  in  the 
vicinity  of  a  joint  one  should  always  think  of  the  possibility  of  their 
communicating  with  the  joint.  In  such  cases  the  tumour  is  only  re- 
moved when  it  causes  serious  trouble. 

Angeioma  {Blood-vessel  Tumour). — The  angeioma  is  made  up 
principally  of  newly  formed  and  old,  dilated,  hypertrophied  blood- 
vessels. Pibbert  claims  that  angeiomata  are  limited  to  the  blood-ves- 
sels in  which  they  first  develop — i.  e.,  they  grow  by  enlargement  of 
the  original  tumour,  and  not  by  involving  neighbouring  capillaries. 
Three  varieties  are  distinguished  : 


Y90 


TUMOURS. 


1.  The  angeioma  simplex  (telangeiectasis,  nseviis  vasculosus,  plexi- 
form  angeioma)  consists  of  dilated,  tortuous,  and  newly  formed  capil- 
laries and  small  vessels.  Macroscopically,  the  telangeiectases  are  mostly 
soft  swellings,  bright-  to  dark-red  in  colour,  which  are  only  slightly 
elevated  above  the  surface  of  the  skin,  where  they  are  usually  found. 
The  origin  of  the  cells  of  the  nsevus  is  given  differently  by  different 
authorities.  Unna  claims  that  they  originate  from  the  epithelial  cells, 
and  others  regard  them  as  connective-tissue  cells.  Nsevi  are  very  often 
cono-enital,  forming  the  so-called  birth-marks.  Multiple  naevi  often 
have  a  special  distribution  over  the  body,  and  are  then  thought  to 
be  caused  l)y  intrauterine  disturbances  of  trophic  or  vasomotor  nerves 
or  bv  disturbances  of  development  in  certain  areas  of  the  skin.     These 

birth-marks  are  often  associated  with  hy- 
pertrophy and  pigmentation  of  the  skin, 
and  very  frequently  with  hair-formation 
(see  Figs.  478-481).  Many  of  these  hairy 
birth-marks  are  diffuse,  soft  fibromata, 
others  more  like  telangeiectases.  The 
hair-formation  often  resembles  the  hide  of 
animals,  such  as  rats,  monkeys,  or  rabbits. 
The  mothers  of  such  children  often  say — 
as  in  the  cases  illustrated  in  Figs.  478,  479 
— that  they  were  frightened  during  preg- 
nancy by  the  sudden  appearance  of  the  ani- 
mal whose  skin  resembles  that  of  the  birth- 
mark. The  marked  heteroplastic  develop- 
ment of  hair  on  certain  parts  of  the  body 
which  are  covered  with  an  otherwise  normal 
skin — the  growth  of  a  beard  in  women,  for 
example  (hypertrichosis  circumscripta) — 
and  the  growth  of  hair  over  the  entire  body  (hypertrichosis  univer- 
salis), have  nothing  to  do  with  tumour-formation  ;  it  is  mostly  a  heredi- 
tary malformation  which  is  found  in  certain  families.  Several  families 
of  hairy  people  are  known  in  which  the  complete  covering  of  the  body 
with  hair  Avas  inherited  by  the  children.  Fig.  480  represents  Schwe- 
Maong,  the  father  of  an  Asiatic  hairy  family,  and  Fig.  481  the  Russian 
hairy  man  Andrian,  whose  son  had  the  same  peculiarity.  Treatment 
by  the  galvano-cautery  may  be  used  for  this  abnormity. 

2.  The  angeiomata  also  include  the  aneurysma  anastomoticum  or 
racemosum,  which  is  best  called  angeioma  arteriale  racemosum  or  cir- 
soid aneurism,  and  has  been  described  in  a  previous  chapter  (Fig. 
482).     The  cirsoid  aneurism,  as  we  saw  on  page  555,  is  the  result  of 


Fig.  470. — Very  large  congenital 
hairy  birth-inark'on  the  back, 
necli,  and  upper  extremity  of  a 
twelve-year-old  girl  (Beigel  and 
Paget)/ 


128.] 


THE   DIFFERENT   VARIETIES  OF  TUMOURS. 


791 


Fig.  480.  —  Shwe-Maong, 
ancestor  of  an  Asiatic 
hairy  family. 


a  pampiniform  dilatation,  tortnositj,  and  thickening  of  the  arteries 
supplying  a  certain  region,  and  is  due  partly  to  the  formation  of  new 
vessels  and  partly  to  hypertrophy  of  the  old  ones. 

3.  The  cavernous  angeioma  (tumor  cavernosus)  resembles  in  struc- 
ture the  corpus  cavernosum — i.  e.,  it  consists  of  cavities  lined  with 
endothelium,  which  are  filled  with  fluid  or  coagu- 
lated blood,  and  separated  by  connective-tissue 
septa.  It  is  most  commonly  found  in  old  people 
in  the  liver,  skin,  or  subcutaneous  tissue ;  less 
often  in  the  brain,  spleen,  kidneys,  uterus,  or  bone. 
The  views  as  to  its  origin  do  not  agree.  Accord- 
ing to  Rokitansky,  the  cavernous  spaces  are  first 
formed  from  the  connective  tissue,  and  then  sec- 
ondarily become  joined  with  the  blood-vessels 
and  thus  filled  with  blood.  Another  explanation 
seems  to  me  the  more  probable,  viz.,  that  a  dila- 
tation of  the  capillaries  first  takes  place,  and  sub- 
sequently the  walls  of  the  dilated  capillaries  which  lie  next  one  another 
gradually  disappear,  resulting  in  the  formation  of  large  cavities  filled 
with  blood. 

Angeioma  is  not  infrequently  combined  with  fibroma,  lipoma,  and 
sarcoma  (angeiosarcoma). 

The  treatment  of  angeiomata  consists  in  their  extirpation  with  the 
knife,  if  possible,  or  with  the  galvano-cautery  or  thermo-cautery  (so- 
called  ignipuncture  or  punctiform  ustion).  In  order  to  operate  with- 
out loss  of  blood,  the  base  of  the  angeioma 
may  in  appropriate  cases  be  transfixed  and 
tied  off  in  two  or  more  parts,  or  portions 
of  the  tumour  may  be  seized  by  clamps 
before  they  are  divided.  Billroth  applied 
two  perforated  lead  plates  to  the  base  of 
the  tumour,  which  were  joined  by  silver 
wire  drawn  tight,  thus  making  an  artifi- 
cial pedicle  which  allowed  the  tumour  to 
be  removed  almost  without  loss  of  blood. 
In  other  instances  he  applied  a  chain  su- 
ture— i.  e.,  the  tumour  is  lifted  up,  clamped 
at  its  base,  and  underneath  the  clamp  in- 
terrupted sutures  are  applied  in  such  a 
way  that  every  suture  takes  in  a  small  part  of  the  tissue  that  is  included 
in  the  previous  suture.  Large,  diffuse  angeiomata,  like  cirsoid  aneu- 
risms, may,  if  removal  is  impossible,  be  treated  by  ligation  of  the  affer- 


FiG.  481. — Andrian,  a  Eussian  hairy 
man  (  Virchow  and  Bartels). 


r92 


TUMOURS. 


ent  arteries  combined  with  ignipuncture.  Cirsoid  aneurism  occurs 
most  commonly  on  tlie  scalp,  and  in  this  situation  might  require  liga- 
tion of  the  external  carotid.     If  the  main  artery  is  too  short,  each  of 

its  l)ranches  should  he  secured. 
It  is  dangerous  to  ligate  the 
common  carotid  on  account  of 
the  changes  which  may  thus  be 
produced  in  the  cerebral  circu- 
lation. For  the  purpose  of  pi'e- 
venting  recurrences  it  is  often 
advisable  to  apply  to  the  dis- 
eased part  for  a  considerable 
time  dressings  which  exert  pres- 
sure, or  to  paint  it  with  iodo- 
form collodion.  Nsevi  which 
cover  a  large  surface  or  are  very 
numerous  and  cannot  be  extir- 
pated can  be  successfully  treated 
by  Mikulicz's  method.  The  epi- 
dermis and  uppermost  layer  of 
the  corium  are  removed  with  a 
microtome  knife  under  strict 
aseptic  precautions.  It  is  abso- 
lutely essential  to  avoid  suppu- 
ration ;  a  dry  dressing  is  ap- 
plied, which  is  kept  on  for  two 
to  three  weeks  until  cicatrisa- 
tion has  taken  place.  In  some  cases  the  operation  is  performed  at  sev- 
eral sittings  three  to  four  weeks  apart.  Among  other  methods  which 
have  been  recommended  are  electrolysis,  parenchymatous  injections  of 
the  tincture  of  iodine,  liquor  ferri  subsulphatis  (Monsell's  solution), 
absolute  alcohol,  liquor  Piazza  (sodii  chlor.  15.0  grammes ;  liq.  ferri 
sesquichlorati  [thirty  per  cent.],  20.0  cubic  centimetres  ;  aq.  destih,  60.0 
cubic  centimetres  [St.  Germain]  ).  Care  should  be  taken  not  to  make 
the  injection  into  healthy  subcutaneous  tissue.  Gunn  and  Haven  speak 
well  of  the  injection  of  carbolic  acid  (ninety-five  per  cent.  acid,  carbol. 
and  glycerine,  aa)  into  the  peripheral  parts  of  the  angeioma  (a  few 
drops  in  from  five  to  fourteen  different  places).  Setons  made  of  threads 
saturated  in  liquor  ferri  subsulphatis,  and  then  dried  and  passed  through 
the  growth,  used  to  be  employed,  as  were  also  ligation  (see  page  78), 
cauterisation  with  fuming  nitric  acid,  etc.  These  are  all  methods  of 
treatment  which  have  now  become  obsolete. 


Fig.  482. — Angeioma  arteriale  racemosum  (cirsoid 
aneurism)  of  the  arteriale  augularis  and  fron- 
talis dextra  et  sinistra  of  a  twenty-year-old 
man  fBruns).  Ligation  of  the  riglit  external 
carotid  and  left  common  carotid.  Death  duo 
to  cerebral  embolism. 


128.] 


THE   DIFFERENT   VARIETIES   OF   TUMOURS. 


793 


Lymphangeioma  {Angeioma  Lymphaticum,  Lymjphangeiectasis). — 
The  lymphangeioma  corresponds  to  the  angeioma  of  the  blood-vessels, 
and  consists  essentially  of  dilated  and  hypertrophied  lymph  vessels 
(Fig.  tl:83).  The  following  varieties  may  be  distinguished  :  1,  lymphan- 
geioma simplex  (telangeiectasia  lymphatica) ;  2,  cavernous  (lymphan- 
geioma cavernosum)  (Fig.  483) ;  and  3,  cystic  lymphangeioma  (lymphan- 
geioma cysticum).  Some  lymphangeiectases  are  acquired  and  others 
are  congenital.  According  to  Eibbert,  lymphangeioma  is  an  independ- 
ent, self -limited  tumour  made  up  of  connective  tissue  and  lymphatics, 
in  whose  growth  all  the  tissue  elements  take  an  equal  part.  Lymphan- 
geiectasis,  on  the  other  hand,  is  not  an  independent  cii'cumscribed  for- 
mation ;  the  dilatation  occurs  in  vessels  which  -are  normally  present  in 
a  tissue.  With  the  dilatation  there  is  a  simultaneous  thickening  of  the 
walls.  The  great  majority  of  lymphangeiomata  are  probably  due  to 
disturbances  of  embryonic  development ;  a  simple  lymph  stasis  would 
not  be  sufficient  to  explain  them,  although  it  can  favour  the  growth  of 
a  lymphangeioma  which  already  exists,  and  particularly  the  formation 
of  cysts.  In  the  formation  of  epithelial  cysts  the  proliferation  of  the 
connective  tissue  and  the  enlargement  of  the  cavities  take  place  at  the 
same  time.  The  lymphangeiectasi^e  usually  communicate  directly  with 
the  lymph  vessels,  and  in  one  case  Nasse  was  able  to  demonstrate  an 
open  connection  between  a  cavernous  lymphangeioma  of  the  neck  and 
the  subclavian  vein  and  thoracic  duct — a  circumstance  which  can  only 
be  explained  on  the  grounds  of 
a  disturbance  of  embryonic  de- 
velopment, as  mentioned  above. 

In  consequence  of  this  com- 
munication of  a  lymphangeio- 
ma with  veins  caused  by  ab- 
normalities in  foetal  develop- 
ment, large  blood-cysts  are 
formed,  especially  on  the  neck 
(Bayer).  The  congenital 
lymph-angeiectatic  hypertro- 
phy of  the  tongue  (macroglos- 
sia)  and  of  the  lips  (macrochei- 
lia)  belong  to  the  congenital 
lymphangeiomata.  Lymphan- 
geiomata sometimes  reach  a  very  considerable  size 
they  contain  is,  as  a  rule,  clear,  but  sometimes  milky. 


Fig  4S0 — Lj  mphangeioma  ca\cinoMiip  of  the  sub- 
cutaneous cellulai  ti^buc  ot  the  neck  conM&ting 
ot  enlaiged  lymph  \esi5el&  with  hypertrophic 
walls.     X  30. 


The  fluid  which 
Ly  m  phangei  om  a 

is  sometimes  complicated  by  inflammatory  manifestations.     If  one  rup- 
tures, a  lymph orrhoea  or  lymph  fistula  results,  through  which  large 


794  TUMOURS. 

araoinits  of  this  fluid  may  escape  (see  page  504),  Ljmphangeiectases 
are  very  often  found  in  connection  with  the  diffuse  hyperplasia  of 
connective  tissue  forming  the  so-called  elephantiasis  (elephantiasis 
lymphangeiectatica,  see  page  540). 

The  treatment  of  lymphangeioma  has  already  been  spoken  of. 
"When  possible,  it  consists  in  extirj^ation  of  the  growth — a  procedure 
which  is  sometimes  very  dithcult.  Sim^^le  incision  and  drainage,  or 
jjacking  with  iodoform  gauze,  may  prove  effective  in  cystic  tumours ; 
but  this  method  should  not  be  used  when  numerous  small  cavities  are 
present.  Bergmann  has  obtained  very  good  results  from  extirpation, 
and  Rehn  successfully  removed  a  lymphangeioma  cavernosum  of  the 
sacral  canal  which  pressed  upon  the  cauda  equina. 

Myoma  {Muscle  Tumour). — The  'myoma  is  made  up  essentially  of 
muscle  fibres,  which  may  be  either  striated  (rhabdomyoma,  myoma 
strio-cellulare)  or  non-striated  (leiomyoma,  myoma  Isevicellulare,  Fig. 
484).  Simple  rhabdomyomata  are  very  rare,  the  myosarcoma  being 
the  most  common  tumour  of  striated  muscle.  Striated  muscle  fibres 
and  spindle  cells  with  striations  are  often  seen  in  sarcomata  of  the 
testicle,  kidney,  and  in  tumours  of  the  ovary  (myosarcoma).  Probably 
in  such  cases  strayed  embryonic  muscle  cells  have  become  deposited 

in  these  organs.  The  leiomyoma  is 
most  common  in  the  uterus  and  intes- 
tinal tract,  where  it  takes  the  form  of 
nodular  tumours,  which  are  more  or 
less  pure  myomata  or  fibro-myomata. 
Microscopically,  the  non-striated  mus- 
cle fibres  are  recognised  on  longitudinal 
section  by  the  rod-like  nuclei  and  their 
regular  arrangement.     On  cross  section 

Fig.    484. — Leiomyoma   of   the   uterus;       .^^'^  .       •    ,•  .  /•  .i       j2i 

some  of  the  nuclei  of  the  muscle  fibres     the  characteristic  contours  ot  the  fibres 
!;^^s'?:nsvSselr'^m  "• '  '"'     ^rc  Seen,  together  with  the  transverse 

section  of  the  nuclei,  in  their  interior 
(Fig.  484).  The  leiomyomata  of  the  uterus  often  take  on  secondary 
changes,  such  as  extensive  fatty  degeneration,  calcification,  cyst  forma- 
tion, and  suppuration.  They  are  occasionally  combined  with  sarcoma 
and  carcinoma.  Multiple  myomata  sometimes  occur  in  the  skin,  orig- 
inating from  cutaneous  muscular  elements. 

The  treatment  of  myomata — for  example,  of  the  uterus  is  in  the 
main  the  same  as  that  of  fibroma  (see  page  782). 

Neuroma  {JSferve-fihre  Tumour). — The  neuroma  is  made  up  essen- 
tially of  newly  formed  nerve  fibres.  A  distinction  is  made  between 
true  and  false  neuroma.     Most  neuromata  are  false — that  is,  they  are 


138.] 


THE  DIFFERENT   VARIETIES   OF   TUMOURS. 


795 


fibromata  or  mjxomata  of  the  connective-tissue  portion  of  nerves,  Tvitli 
displacement  and  atrophy  of  the  nerve  fibres.  They  generally  form 
flask-like  swellings  of  the  nerves,  or  cylindrical  or  si^herical  timiours, 
about  the  size  of  a  bean,  cherry,  or  plum,  and,  in  rare  cases,  the  size  of 
a  hen's  egg.  The  false  neuromata  are  often  multiple.  Bergmann,  for 
instance,  observed  more  than  a  hundred  neuro-fibromata  of  the  skin 


Fig.  485. — Plexiform  neuroma :  specimen  from  the  case  shown  in  Fig.  486. 

in  a  man  fifty-four  years  old.  The  so-called  amputation-neuromata, 
which  are  club-shaped  swellings  of  the  ends  of  the  nerves  in  am- 
putation-stumps, are,  as  a  rule,  made  up  mostly  of  newly  formed 
connective  tissue,  with  more  or  less  numerous  collections  of  new  nerve 
fibres.  The  so-called  plexiform  neuroma  also  belongs  to  the  false  neu- 
romata or  fibro-neuromata.  It  is  essentially  a  nodular,  fibrous  degen- 
eration of  the  branches  of  a  particular  nerve,  the  trunk  of  which  be- 
comes twisted  and  tortuous  (Fig.  485).  Instead  of  a  plexus  of  strongly 
developed  nerve  fibres  that  have  undergone  fibrous  degeneration,  as 
shown  in  Fig,  485,  we  sometimes  find  a  single  large  nerve  trunk,  with 
numerous  branches,  which  shows  at  some  points  localised  swellings — i.  e., 
small  fibromata,  and  is  embedded  in  a  gelatinous  stroma  (Tietze).  These 
plexiform  neuromata,  of  which  the  rudiments  were  present  in  the  em- 
bryo, are  very  much  like  soft  fibromata  of  the  skin  and  subcutaneous 
cellular  tissue,  in  which  they  form  flabby,  lobulated  folds  and  elevations 
(Fig.  486),  sometimes  uneven  and  nodulated,  usually  containing  dark 
pigment  and  covered  with  hair,  as  in  elephantiasis  (Fig.  468).  Yery 
large  tumours  sometimes  result  from  this  elephantiasis-like  hyperplasia 
of  the  skin  and  subcutaneous  tissue.     The  plexiform  neuroma  is  almost 


796 


TUMOURS. 


always  situated  in  the  subcutaneous  tissue,  and  only  exceptionally  in 
the  deeper  parts,  as  in  a  case  seen  by  Pomorski,  in  which  a  plexiform 
neuroma  of  the  intercostal  nerves  had  ffrown  into  the  pleura.  Bruns 
collected  from  literature  a  large  number  of  instances  of  plexiform  neu- 
roma, and  found  that  its  most  common  location  is  on  the  temples  and 

upper  eyelid  (fifteen 
cases).  It  was  found 
eight  times  in  that 
part  of  the  neck 
which  lies  posterior 
to  the  ears,  three 
times  on  the  nose 
and  cheek,  four 
times  near  the  lower 
jaw  and  front  of  the 
neck,  seven  times  on 
the  breast  and  back, 
and  three  times  on 
the  extremities. 

The  tt'ue  neu- 
romata consist  for 
the  most  part  of 
newly  formed  nerve 
fibres,  which  devel- 
op in  one  or  more 
peripheral  nerves. 
Some  cases  of  am- 
putation neuromata 
also  belong  to  this 
class  of  tumours.  Depending  upon  whether  the  neuroma  is  made  up 
of  medullated  or  non-medullated  nerve  fibres,  we  make  a  distinction^ 
as  Yirchow  does,  between  a  neuroma  myelinicum  and  a  neuroma 
amyelinicum.  The  brain  and  certain  neoplasms  of  the  testicle  and 
ovary  are  sometimes  the  seat  of  a  cellular  (ganglionic)  neuroma.  The 
neuroma  is  in  general  a  benign  tumour,  though  it  is  sometimes  mul- 
tiple in  the  nerves  of  the  brain  and  spinal  cord. 

In  rare  cases  neuromata  are  found  to  be  malignant,  gi\ang  rise  to 
local  recurrences  after  extirpation,  and  even  to  metastases  (Fig.  487). 
Garre  distinguishes  primary  and  secondary  malignant  neuromata ;  the 
former  are  chiefly  the  sarcomata  of  nerves,  while  the  secondary  malig- 
nant neuromata  result  from  sarcomatous  changes  in  a  previously  benign 
neuro-fibroma.     The  above-mentioned   multiple  neuro-fibromata  also 


Fig.  486. — Plexiform  neuroma  of  tlie  lower  part  of  the  face  and 
neck,  on  the  right  side,  in  a  boy  ten  years  old  ( Bruns j. 


§  128.] 


THE   DIFFEREXT   VARIETIES   OF   TOJOURS. 


T97 


I. 


Fig.  457. — Neuroma  amyelinicum  mul- 
tiplex recurrens  ulcerosum  antibrachii. 
Most  of  the  nodules  lie  beneath  the 
skin  :  a,  ulcerating  nodule  ;  b,  scar  from 
a  previous  extirpation  of  the  primary 
neuroma  (Tirchow). 


undergo  in  some  eases  malignant  clianges  ;  Garre  lias  collected  sixteen 
cases  of  tliis  sort  from  literature.  According  to  Goldmann,  the  malig- 
nant degeneration  of  benign  neuro- 
fibromata  depends  not  so  much  upon  a 
cbano-e  in  the  anatomical  character  of 
the  tumour  as  upon  changes  in  the  en- 
tire organism.  Histologically  the  pri- 
mary malignant  neuromata  are  usually 
medullary,  round,  and  spindle-celled 
sarcomata,  or  dense  fibrous  neuromata, 
\vith  nevertheless  a  very  malignant 
course,  or  finally  myxomata  or  lipoma- 
tous  myxomata.  Central  softening  and 
cyst  formation  are  frequent.  The  ma- 
hgnant  neuromata  usually  start  from 
the  nerve  sheaths,  particularly  the  intra- 
fascicular  tissue  (endoneurium).  They 
may  develop  rapidly  into  tumours  as 
large  as  a  man's  head,  and  occur  par- 
ticularly in  the  large  nerves  of  the  ex- 
tremities— e.  g.,  the  median  and  sciatic — but  not  infrequently  they  start 
from  small  cutaneous  nerve  branches.  Before  metastasis  takes  ]Aaee 
throuo;h  the  circulation,  metastatic  tumours  are  sometimes  formed 
throughout  the  whole  nervous  system.  Biinger  reported  a  very  char- 
acteristic case  of  general  multiple  neuro-fibroma  formation  in  th^ 
peripheral  nervous  system  and  the  sympathetic  system  which  had 
developed  after  a  neuro-fibroma  of  the  external  cutaneous  nerve  of  the 
thigh.  iS'ewly  formed  medullated  nerve  fibres  are  occasionally  found 
in  the  neuromata — a  fact  which  is  not  remarkable,  as  we  know  that 
degeneration  and  regeneration  of  nerve  fibres  take  place  in  normal 
nerves. 

The  so-called  tubercula  dolorosa,  which  appear  as  small,  movable, 
painful,  subcutaneous  tumours,  are,  according  to  Yirchow,  in  some 
instances  true  neuromata,  while  iu  others  it  has  not  been  possible  to 
demonstrate  nerve  fibres. 

As  regards  the  treatment  of  neuroma,  I  may  say  that  neuro-fibrora- 
ata  and  neuro-rayxomata  can  usually  be  removed  and  the  continuity 
of  the  nerve  be  preserved.  If  extirpation  is  not  possible,  as  in  the  case 
of  large  nerves  of  the  extremities,  for  example,  and  the  removal  of  the 
tumour  is  indicated  on  account  of  great  pain,  rapid  growth,  etc.,  the 
continuity  of  the  nerve  must  be  restored,  after  the  extirpation  of  the 
neuroma,  by  means  of  sutures  or  a  plastic  operation.     The  treatment 


'98 


TUMOURS. 


of  a  plexiform  neuroma,  wLicli  involves  the  whole  region  of  distribu- 
tion of  a  nerve,  is  merely  palliative  in  case  extirpation  is  imjjossible. 

Glioma. — Gliomata  occur  especially  in  the  brain,  less  often  in  the  spinal 
cord,  and  result  from  the  growth  of  the  neuroglia  cells  of  the  central  nervous 
system.  They  form  pale-grey,  greyish-white,  oi',  when  very  vascular,  reddish 
or  dark-red  tumours,  which  are  usually  not  sharply  defined.  They  are  not 
infrequently  the  seat  of  retrograde  metamorphoses,  such  as  fatty  degenera- 
tion, caseation,  and  softening.  Under  the  microscope  the  gliomata  are  seen 
to  be  made  up  of  a  network  of  fine  translucent  fibres,  which  contain  branch- 
ing cells  resembling  those  of  the  neuroglia.  According  to  Klebs,  Heller, 
and  others,  many  gliomata  consist  of  growing  ganglionic  cells  and  newly 
formed  nerve  fibres.  Ziegler  is  right  in  separating  these  from  the  gliomata, 
and  calls  them  neuroglioma  ganglionare. 

Lymphoma. — By  lymphoma  we  understand  a  true  neoplasm  as  well 
as  a  chronic  inflammatory  or  infectious  hypertrophy  of  lymph  glands. 
The  latter  may  originate  as  a  result  of  local  and  constitutional  causes. 
In  this  category  belong,  for  example,  the  lymphomata  of  the  neck  fol- 
lowing chronic  inflammation  of  the  skin  or  mucous  membrane  in  the 
region  supplied  by  the  lymphatic  vessels  which  lead  to  the  enlarged 
glands,  also  the  lymphomata  due  to  local  or  general  tuberculosis,  or 
which  occur  in  the  course  of  leucaemia,  and  the  progressive  lymphoma- 

tous  formations  encountered  in  anoma- 
lies of  the  organs  producing  the  blood 
(malignant  lymphoma,  Hodgkiu's  dis- 
ease, pseudo  -  leucaemia).  The  word 
lymplioma  signifies,  in  general,  hyper- 
plasia of  lymph  glands,  but  if  the  en- 
largement is  caused  by  a  true  neoj)lasm, 
we  call  it,  according  to  its  structure,  a 
lympho-sarcoma,  lymph-adenoma,  etc. 
The  above-mentioned  progressive  for- 
mation of  lymphomata  in  Hodgkin's 
disease  is  exceedingly  interesting.  The 
disease  usually  begins  with  a  large  nodu- 
lar swelling  of  the  lymph  glands  of  the 
neck  (see  Fig.  488)  which  is  entirely 
free  from  pain.  As  a  rule,  the  adjoin- 
ing lymph  glands  become  successively  swollen,  then  the  glands  of  the 
other  side,  and,  finally,  in  many  cases  the  mediastinal  and  retroperito- 
neal glands.  The  microscope  shows  a  simple  hyperplasia  of  the  lymph 
glands,  though  Goldmann  observed  in  them  a  marked  increase  in  the 
number  of  cells  which  can  be  readily  stained  by  eosin  feosinophilous 
cells).     Metastases  in  the  internal  organs  are  of  frequent  occurrence 


Fig.  48S. — Soft  malicruant  lymphoma  of 
the  neck  and  both  a.xilite  in  a  boy 
six  years  of  age. 


§128.]  THE   DIFFERENT   VARIETIES   OF   TUMOURS.  Y99 

(lungs,  spleen,  liver,  kidneys,  bone),  and  the  enlargement  of  the  spleen 
may  become  very  marked.  The  general  health  can  remain  undisturbed 
for  a  comparatively  long  time,  but  ordinarily  a  steadily  increasing  loss 
of  flesh  and  strength  soon  sets  in  and  is  followed  by  death.  In  the 
severe  cases  intermittent  rises  of  temperature  usually  occur.  Fischer 
found  staphylococci  in  the  blood  during  the  attacks  of  fever,  which  had 
perhaps  entered  the  circulation  from  the  intestinal  tract.  In  a  number 
of  cases  a  combination  of  malignant  lymphoma  with  tuberculosis  has 
been  observed,  the  patients  then  dying  of  the  tuberculosis.  The  latter 
is  probably  a  secondary  infection  of  the  weakened  organism.  Occasion- 
ally, as  in  goitre,  the  end  comes  suddenly  from  suffocation  in  conse- 
quence of  softening  of  the  laryngeal  cartilages  or  of  paralysis  of  the 
vocal  cords  due  to  bilateral  pressure  on  the  recurrent  nerve.  The  eti- 
ology of  malignant  lymphoma  has  not  been  thoroughly  investigated. 
The  white  blood-corpuscles  are  not  increased  in  numbers  as  in  leucsemic 
lymphoma,  hence  the  name  pseudo-leucaemia.  Malignant  lymphoma 
or  pseudo-leucsemia  is  probal)ly  the  result  of  some  as  yet  unknown, 
infection.     Transitions  to  lympho-sarcoma  sometimes  occur. 

The  treatment  of  lymphoma  varies  according  to  its  cause.  'Neo- 
plasms  of  the  lymph  glands  should  be  extirpated  as  soon  as  possible. 
Tubercular  lymphomata  should  also  be  treated  in  the  same  way,  or 
scraped  out  with  the  sharp  spoon,  or  treated  by  ignipuncture  with  the 
galvano-cautery,  or  parenchymatous  injections  of  ten-per-cent.  iodo- 
form oil  or  iodoform  glycerine,  etc.  I  also  excise  simple,  non-tuber- 
cular, so-called  scrofulous  enlargements  in  case  they  do  not  disappear 
under  a  general  tonic  regimen,  a  thing  which  is  of  great  importance  in 
the  management  of  all  lymphomata.  In  mahgnant  lymphoma  the 
arsenic  treatment  is  sometimes  successful,  both  internally  and  in  the 
form  of  parenchymatous  injections.  Billroth  began  with  ten  drops  of 
Fowler's  solution  ^^rc  die  internally,  and  injected  at  first  two,  subse- 
quently four  to  six  drops  a  day  into  the  substance  of  the  tumour.  The 
internal  dosage  may  be  raised  two  drops  every  third  day,  but  if  symp- 
toms of  poisoning  make  their  appearance  the  doses  must  be  diminished. 
A  cure  is  not  obtained  in  this  way,  but  the  patient  improves  and  the 
course  of  the  disease  is  checked  or  rendered  less  severe.  The  operative 
removal  of  malignant  lymphomata  is  probably  always  unsuccessful,  as 
recurrences  appear,  as  a  rule,  very  promptly.  But  they  should  be 
removed  sufficiently  to  relieve  at  least  the  urgent  symptoms,  such  as 
those  caused  by  obstruction  to  respiration. 

Sarcoma. — The  sarcoma  (Figs.  489, 490)  is  a  neoplasm  which  springs 
from  connective  tissue,  and  is  formed,  in  general,  after  the  type  of 
embryonic  connective  tissue  with  abnormal  and  luxuriant  cell  forma- 


800 


TUMOURS. 


/'^"sw--^ 


''■'•'%,/f/» 


Fig.  489.— Sarcoma  (osteo-sarcoma)  of  the  left  (upper,)  arm 
(Esniarch). 


tion.  The  sarcomata  originate  in  all  varieties  of  connective  tissue  (car- 
tilage, bone,  periosteum,  ordiuarv  connective  tissue,  fat  tissue,  etc.), 
and  are  particularly  likelv  to  start  from  the 
cells  of  the  walls  of  the  blood-vessels.  The 
etiology  of  sarcoma  has  recently  been  advanced 
bv  the  very  interesting  investigations  of  Jiir- 
irens.     The  latter  showed  that  some  sarcomata 

3^  are  infectious  in  nature 

r-     --  and  can  be  inoculated 

-  ^.,.^  upon  animals ;  he  found 
sporozoa  both  in  the 
tumours  and  in  the 
blood  of  the  animals, 
which  explains  the 
early  occurrence  of  me- 
tastases. The  question 
whether  all  sarcomata 
are  of  parasitic  origin 
cannot  at  present  be 
answered  (see  also  pages  816-821,  Etiology  of  Carcinoma).  Benign 
tumours,  as  we  remarked  before,  not  infrequently  become  sarcomatous, 
thus  giving  rise  to  mixed  tumours,  such  as  tibro-sarcoma,  myxo-sarcoma, 
osteo-sarcoma,  etc.  Sarcomata  in  the  skin,  periosteum,  and  marrow  of 
bone  occasionally  appear  in  a  multiple  form.  The  multiple  sarcomata 
of  the  skin  (sarcomatosis  cutis)  sometimes  represent  a  transition  from 

inflammatory  growths  to  real  sarcomata  ;  they 
form  a  group  of  neoplasms  separate  from  the 
latter,  to  which  the  mycosis  fungoides  also  be- 
longs (see  page  511).  The  size  and  shape  of 
the  cells  in  a  sarcoma  vary  considerably  (Figs. 
491-196),  many  being  round  cells,  which  are 
often  contractile,  like  white  blood -corpuscles, 
while  others  are  spindle  cells,  endothelial  cells, 
stellate  cells,  or  giant  cells.  Between  each  of 
these  there  are  numerous  intermediate  cell 
forms,  and  different  shaped  cells  are  often 
found  lying  next  one  another.  There  is  a 
greater  or  less  amount  of  intercellular  sub- 
stance which  may  be  fibrbus,  homogeneous, 
reticulated,  granular,  mucoid,  etc.  The  vas- 
cularity of  sarcomata  also  varies  very  much,  being  occasionally  so 
marked  that  the  tumours  pulsate  like  aneurisms.     They  likewise  show 


Fig.  490. — Sarcoma  (myxo-sar- 
coma) of  the  dura  mater  in  a 
twenty-eight-year-old  man 
(Heineke). 


128.] 


THE  DIFFERENT   VARIETIES  OF  TUMOURS. 


801 


^ 


8  <iyt>/-' 


.S'' 


% 


JZr- 


great  differences  in  consistence  and  colour.  The  very  malignant,  soft, 
rapidly  growing  sarcomata,  made  up  largely  of  cells,  are  especially  to 
be  dreaded  (medullary  sarcoma).  The  pigmented  varieties,  the  melano- 
sarcomata,  are  also  very  malignant.  The  formation  of  metastases  takes 
place,  as  Billroth  showed,  principally  through  the  veins,  and  to  a  less 
extent  through  the  lymphatics.  I  once  found  in  a  case  of  medullary 
sarcoma  of  the  lower  extremity  a  metastatic  deposit  the  size  of  a  small 
pea  in  a  valve  of  the  femoral  vein. 
The  retrograde  changes  which  take 
place  are  fatty  degeneration,  casea- 
tion, softening,  cyst  formation,  hsem- 
orrhage,  and,  after  the  disease  has 
broken  through  the  skin,  ulceration 
and.  sloughing. 

Sarcoma  of  bone  originates  either 
from  the  periosteum  or  from  the  med- 
ullary cavity.  The  latter,  or  myelo- 
genic sarcoma,  is  characterised  by  hav- 
ing a  greater  number  of  giant  cells. 
So  long  as  the  central  (myelogenic) 
sarcoma  of   bone  possesses  a  closed 

capsule  the  prognosis  is  favourable,  but  otherwise  it  is  extremely  bad. 
Out  of  twelve  patients  with  sarcomata  of  the  long  bones  which  were 
removed  with  the  knife,  six  died  from  recurrences,  and  of  the  remain- 
ing six,  two  had  to  be  operated  on  again  very  soon  for  recurrence. 
According  to  the  shape  of  the  cells  and  the  structure  of  the  sarcoma  the 

following  different  forms  are  distinguished, 
which  of  course  often  merge  into  and  com- 
bine with  one  another  to  a  greater  or  less 
extent : 


M 


Fig.  491. — Marginal  portion  of  an  inter- 
muscular sarcoma  of  the  arm :  .S',  sar- 
coma tissue  consisting  of  round  cells  ; 
J/,  transversely  divided  muscular  tis- 
sue. 


1.  The  round -celled  variety  occurs  as  the 
small-  and  large -celled  sarcoma.  The  small 
round-celled  sarcoma  (Fig.  491)  is  made  up  of  cells 
which  resemble  white  blood-corpuscles,  and  as  a 
rule  grows  rapidly,  forming  a  soft  tumour,  which 
on  section  appears  white,  and  when  squeezed 
gives  out  a  milky  fluid.  It  consists  of  round 
cells,  blood-vessels,  and  generally  of  a  very  small 
amount  of  a  fibrous,  granular,  or  homogeneous 
stroma.  In  some  cases  it  has  a  pronounced  alveolar  structure,  and  then  re- 
sembles gland  tissue  or  carcinoma— i.  e.,  the  cells,  or  rather  groups  of  cells, 
are  divided  off  by  connective-tissue  septa  (alveolar  sarcoma.  Fig.  493).  The 
small  round-celled  sarcomata  are  usually  very  malignant  in  character ;  they 
54 


Fig.  492. — Portion  of  a  sarcoma 
of  the  fascia  of  the  thigh 
containing  cells  of  various 
shapes  ("small  and  large  round 
cells,  spindle  cells,  polynucle- 
ated  giant  cells,  etc.).     x  250. 


802 


TUMOURS. 


destroy  the  surrounding  tissues,  forming  metastases  and  running  a  course 
similar  to  carcinoma  (§  129).     The  most  common  locations  for  this  sarcoma 

are  connective  tissue,  muscle,  fascia, 
,  '    >  periosteum,  bone,  lymph  glands,  etc. 


1 


Fig.  493.— Small-celled  alveolar  sarcoma  of  the 
Ivmph  glands  of  the  neck.  The  alveoli 
between  the  connective-tissue  bands  are 
filled  with  sarcomatous  round  cells,    x  150. 


Fig.  49-4. — Large-celled  sarcoma  I'f  the  breast. 
X  300. 


The  large  round-celled  sarcoma  (Fig.  494),  although  it  is  not  quite  so 
malignant  as  the  small-celled  and  does  not  grow  as  rapidly,  is  very  similar 
to  the  latter  in  its  clinical  course.  It  also  occasionally  possesses  an  alveolar 
structure. 

2.  The  spindle-celled  sarcoma  usually  consists  of  cells  which  are  for  the 
most  part  long,  thin,  and  spindle-shaped,  lying  close  together  (Fig.  495),  with 
or  without  a  variable  amount  of  homogeneous  or  fibrous  intercellular  sub- 
stance. If  the  latter  is  fibrous  and  abundant  the  tu- 
mour is  called  a  fibro-sarcoma. 

3.  The  giant-celled  sarcoma  is  characterised  by 
the  presence  of  a  great  number  of  very  large,  poly- 
nuclear,  round,  or  polymor- 
phous cells  (Fig.  496),  and 
originates  most  commonly 
in  bone  marrow  (myelogenic 
osteo-sarcoma).  Giant  cells 
are  also  occasionally  found 
in  the  round  and  spindle- 
celled  sarcomata,  but  not  by 
any  means  in  such  quantities 
as  in  the  true  giant-celled 
neoplasm. 

4.  Stellate  or  reticular- 
celled  sarcomata  are  most 
commonly  encountered  in 
myxomata  and  myxo-chondromata  which  are  combined  with  sarcoma.  The 
stellate  or  reticular  cells,  with  their  interlocking  processes,  are  usually  em- 
bedded in  a  soft,  gelatinous,  mucoid  intermediary  substance. 

5.  In  many  sarcomata  cells  of  all  varieties  of  shapes  are  found  together 
(sarcoma  with  polymorphous  cells,  Fig.  492). 


Fig.  495.  —  Cells  from  a 
spindle-celled  sarcoma 
of  the  thigh,     x  300. 


Fig.  490.  —  Cells  from  a 
myelogenic  giant-celled 
sarcoma  of  the  lower 
jaw.     X  300. 


§  128.]  THE   DIFFEKEXT   VARIETIES   OF   TUMOURS.  803 

6.  The  alveolar  sarcoma  (Fig-.  493)  -whicli  was  mentioned  above  is  made 
up  of  mononuclear  and  polynuclear  cells,  as  a  rule  about  as  large  as  average- 
sized  pavement  epithelial  cells,  which  lie  singly  or  in  groups  in  a  fibrous,  less 
often  in  a  homogeneous  intermediary  substance.  A  characteristic  feature  of 
this  variety  is  that  the  cells,  contrary  to  carcinoma,  are  closely  united  to  the 
connective-tissue  stroma,  and  cannot  be  easily  separated  from  the  fibrous 
meshes.  Although  this  forms  the  means  of  distinguishing  the  alveolar  sar- 
coma from  carcinoma,  yet  sections  of  the  two  tumours  under  the  microscope 
often  present  such  similar  pictures  that  it  is  very  diificult  to  recognise  one 
from  the  other. 

7.  The  j^lexiform  angeio-sarcoma  (Waldeyer)  is  to  be  looked  upon  as  an 
angeioma  with  a  sarcomatous  growth  of  the  walls  of  the  vessels  ;  it  originates 
mainly  by  growth  of  the  endothelial  cells  which  lie  next  the  adventitia  of 
both  the   lymph  and  blood-vessels 

(Fig.  497).     These  cell  growths  sur-  ^  ,,  '\4^!^'^r^^---^-  ^-"^/^^^ 

round  the  walls  of  the  vessels  like  a  '     ,      ^     /'^^'^•^v's^^^^-r^l^-?; 

sheath,  and,  as  a  growth  of  the  inner       '  '       ^''^SS^^^^  '         ^ 


endothelial  cells  also  takes  place,  the  ".                \ 
lumen  of  the  blood  or  lymph  vessel 
in  question  may  finally  become  en- 
tirely occluded.     The  I'eticulated  an-  '   '   '—.''•"-*":-.'•               -'"/' 
astomosing  filaments  and  tubules  of  ^'-^                                                       "    ^ 
the  cells  usually  lie  in  fibrillar  con-  '  ^                                        -  ,     "    -..:^ 
nective  tissue,  and  as  a  result  of  hya-  "                 Z^^      "'■  ~      \.     '•  • ,'-    '"I 
line  degeneration  of  the  walls  of  the  '^^-^<  "          -    "           '  --^ 
vessel  hyaline   tubules  are   formed  <                   "          --.  ■  * 
having  cells  in  their  interior,  or  the  "W^«.::x^^.j5-Vv  X  4,A;;..V''            ■^  V'— ' 
latter  is   so  narrowed  by  the  hya-  "  ^i^"- '-^^^-^^^^^-^LT^^^-'S^    -      \"^--\ 
line  degeneratioii  that  only  hyaline  ■'^''<-^j;if              ^ 
branching  cords,  bulbs,  or  spherules  Fig   4y7.-Plexitorm  angeio-sarcoma,  or  endo- 
*=              '                1       /-f          •  thelioma,  ot  the  thigh.     The  anastomcsing 
without  cells  are  found.      Occasion-  groups  of  cells  are  derived  in  this  instance 
ally  the  hyaline  degeneration  attacks  |^°"^  proliferation  of  the  endothelium  of  the 
y        _     -^                  >=     _  lymph  vessels ;  they  surround  the  latter  like 
primarily  the    cells   in   the   tubules,  a"  sheath.     In  some  places  the  groups  of 

so  that  the  hyaline   cords    are    sur-  ^^^V^'  ""?  endothelium,  are  in  solid  masses, 

"■    ^      J  _  while  m  others  they  have  undergone  de- 

rounded  by  cells  which  have  not  yet  generation,     x  so. 

become  degenerated.    The  plexif  orm 

angeio-sarcoma  is  really  an  endotheliosarcoma  or  endothelioma,  and  on 
account  of  the  hyaline  cylinders  this  tumour  was  once  called  a  cylindroma. 
Yolkmann  has  recently  made  a  careful  study  of  endothelioma.  It  is  fairly 
common,  and  varies  a  good  deal  macroscopically  and  microscopically.  The 
cells  undergo  various  forms  of  degeneration  and  show  a  very  variable  group- 
ing (alveolar,  cylindrical,  etc.).  The  tumours  are  sometimes  encapsulated 
and  sometimes  more  diffuse,  with  a  very  variable  energy  of  growth  and  capa- 
bility of  recurrence.  Some  of  the  endotheliomata,  on  account  of  their  diffuse 
growth,  are  not  to  be  regarded  as  true  neoplasms,  but  rather  as  infectious 
tumours.  The  endothelioma  arises  in  some  cases  from  the  endothelium  of 
the  blood-vessels,  and  in  others  from  the  endothelioma  of  the  lymphatics  or 
connective  tissue.  Kiister  rightly  called  attention  to  the  fact  that  there  are 
ha^morrhagic  sarcomata  or  angeio-sarcomata  (endotheliomata)  which  show 


804 


TUMOURS. 


extensive  degeneration  of  the  walls  of  vessels— i.  e.,  growth  of  endothelial 
cells  and  hyaline  degeneration— before  a  tumour  nodule  has  become  devel- 
oped;  they  lead  to  ha^matomata  without  macroscopically  visible  sarcoma 
tissue.    In  other  cases  such  ha^matomata  are  followed,  months  after,  perhaps, 


bv  remarkablv  malignant  sarcomata. 


\  jS',' 


The  plexiform  angeio-sarcoma  or  en- 
dothelioma is  anatomically 
easily  mistaken  for  carci- 
noma, and  runs  a  similar 
course — i.  e.,  it  is  a  marked- 
ly malignant  tumour,  re- 
curs after  extirpation,  and 


|i''.,;^>Oi  causes  at  a  comparatively 
^     early  period  an  infection  of 


w 


Fig.  49S. — Xanthelasma  tuberosum.  Hsematoxj-lin  stain. 
The  fat  was  dissolved  by  treatment  with  alcohol  and 
origanum  oil,  and  the  specimen  enclosed  in  Canada 
balsam,     x  GOO. 


the  nearest  lymph  glands 
and  metastases.  Hence 
some  authors  have  desig- 
nated the  malignant  en- 
dothelioma as  endothelial 
cancer.  This  endothelial 
cancer,  consisting  of  con- 
nective-tissue cells,  must,  of 
course,  be  sharply  differen- 
tiated from  epithelial  car- 
cinoma. The  formation  of 
metastases  in  endothelial  cancer  is  very  characteristic.  Groups  of  cells  grow 
from  the  primary  tumour  into  the  lymph  spaces;  the  secondary  nodules  are 
joined  together  and  with  the  primary  tumour  by  connecting  bands  which  are 
often  visible  to  the  naked  eye.  The  diseased  lymph  glands  are  noticeably 
soft,  very  much  enlarged,  and  painless ;  the  cells  of  the  endothelioma  are 
most  numerous  at  the  hilum,  and  from  here  send  out  fine  i3rocesses  into  the 
medullary  substance. 

The  xanthoma  or  xanthelasma,  a  sulphur-yellow  or  brownish-yellow  pig- 
mentation of  the  skin,  is,  according  to  De  Vincentiis,  Touton,  and  others,  an 
endothelioma  in  which  fat  has  been  deposited  (endothelioma  lipomatodes) ; 
it  grows  from  the  endothelium  of  the  lymphatic  vessels.  The  peculiar  colour 
of  the  xanthoma  is  due  to  the  deposit  of  fat  in  the  cells.  The  drops  of  fat 
are  sometimes  so  numerous  and  close  together  in  the  interior  of  the  cells  that 
the  latter  are  difficult  to  recognise.  After  the  fat  has  become  dissolved  the 
cells  clear  up,  and  in  place  of  the  fat  drops  there  are  corresponding  gaps  in 
the  cells  (Fig.  498).  It  occurs  in  a  fiat  (xanthoma  planum)  and  nodular 
(xanthoma  tuberosum)  form,  especially  on  the  eyelids,  though  occasionally, 
it  has  a  multiple  character,  appearing  on  different  parts  of  the  body,  particu- 
larly where  there  are  folds  of  skin  (flexor  side  of  joints,  axilla,  neck.  etc.). 
Now  and  then  the  eruption  occurs  more  or  less  suddenly — in  the  course  of 
diabetes,  for  example  (xanthoma  diabeticura) — at  other  times  symmetrically, 
probably  from  tropho-neurotic  disturbances.  Occasionally  it  changes  into 
sarcoma  or  fibroma  (sarco-xanthoma.  fibro- xanthoma). 

The  villous  sarcoma,  the  so-called  cholesteatoma,  which  may  be  en- 
countered on  the  meninges  of  the  brain,  probably  owes  its  origin  likewise 


§  128.] 


THE   DIFFERENT   VARIETIES   OF   TUMOURS. 


805 


to  growth  of  the  endothelial  cells  of  the  vessels,  or  of  the  cells  of  their 
sheaths. 

Perhaps  the  psammoma  of  the  brain  and  orbit  described  by  Virchow  also 
belongs  to  the  endotheliomata.  They  are  characterised  by  the  presence  of 
large  amounts  of  lime  concretions  similar  to  the  "  brain  sand  "  normally 
present  in  the  hypophysis  cerebri.  Such  concretions  are  met  with  in  sar- 
coma, fibroma,  and  myxoma,  and,  according  to  Billroth,  are  to  be  regarded 
as  calcified  bundles  of  endothelial  cells  which  are  attached  to  the  blood- 
vessels, though  Virchow  thinks  they  are  also  the  result  of  the  calcification  of 
connective  tissue. 

The  melano-sarcoma  (pigmented  sarcoma)  is  characterised  by  the  presence 
of  a  brown  or  black  pigment  which  is  almost  always  deposited  in  the  cells, 
less  often  in  the  intercellular  substance  and  walls  of  the  vessels.  On  section 
the  melanomata  are  brown,  or,  if  the  pigmentation  is  excessive,  black  in 
colour.  The  pigmented  cells  sometimes  have  branches  and  resemble  the 
chromatophores  of  the  choroid  membrane,  and  others  are  large,  round  cells  ; 
transition  forms  between  the  two  also  occur.  They  are  among  the  most 
malignant  tumours,  their  growth  being  sometimes  very  rapid  and  the  num- 
ber of  metastases  considerable  (see  Fig.  499).  They  are  most  likely  to  develop 
in  places  where  pigment  is  already  present — as  in  freckles  or  pigmented 
warts,  for  example  (Fig.  499)— and  most  commonly  begin  on  the  extremities. 
The  origin  of  the  pigment  is  doubtful.     According  to  Gussenbauer,  it  is 


Fig.  499.— Melanoma  of  the  skin  fraan  seventy-four  years  old)  oriorinating  in  a  pigmented  wart 
upon  the  back  ;  within  six  months  over  one  hundred  pigmented  spots  and  tumours  formed 
upon  the  skin.  Numerous  melano-sarcomata  of  the  pleura,  lungs,  pericardium,  liver,  kid- 
neys, and  retroperitoneal  glands  were  found  (Liicke). 


formed  from  the  red  blood- corpuscles  of  the  thrombosed  vessels,  while  others 
think  that  it  is  not  identical  with  the  pigment  resulting  from  haemorrhages, 
but  may  be  due  to  a  special  activity  of  the  cells  (Birch-Hirschfeld).  Schmidt 
considers  the  pigment  to  be  haematogenous  in  nature,  having  passed  the 
hsemosiderin  stage  and  parted  with  its  iron  reaction.    The  general  melanosis 


8()(]  TUMOURS. 

that  follows  the  development  of  melanotic  sarcomata  of  the  skin  is  caused 
by  embolic  extension  of  the  tumours  (Tietze). 

Terrillon  observed,  in  a  case  of  melanosis  which  ran  a  rapidly  fatal  course, 
an  increase  in  the  number  of  white  corpuscles  in  the  blood  and  a  large  num- 
ber of  "  black  bodies."  The  amount  of  haemoglobin  in  the  blood  is  usually 
diminished,  rarely  increased.  Melanuria  is  encountered  in  rare  instances  of 
multiple  melanoma,  and  Zeller  found  variable  amounts  of  hydrobilirubin, 
melanin,  and  melagon  in  the  dark-brown  but  otherwise  perfectly  clear  urine. 
The  urine  in  melanosis,  when  first  passed,  is  clear,  but  if  allowed  to  stand 
becomes  black,  and  at  times  almost  the  colour  of  ink.  Before  death  the 
freshly  passed  urine  sometimes  looks  like  black  pitch. 

The  question  of  the  transmissibility  of  melanoma  has  been  experiment- 
ally studied  by  Lanz,  Tietze,  and  Jlirgens.  The  latter's  inoculation  experi- 
ments were  successful ;  within  two  to  three  weeks  melano-sarcomata  devel- 
oped in  the  peritonaeum,  and  metastases  were  formed.  Coccidia  were  always 
present.  Lanz  injected  into  a  guinea-pig  a  certain  amount  of  an  infusion  of 
melanotic  cutaneous  nodules,  melanotic  brain,  liver,  and  spleen.  The  animal 
died  a  mouth  and  a  half  after  the  injection,  and  the  autopsy  showed  collec- 
tions of  i^igment  in  many  different  parts  of  the  bodj'  (skin,  subcutaneous 
tissue,  muscles,  peritonaeum,  spleen,  liver,  kidneys,  etc.).  In  this  case  the 
pigment  must  have  been  formed  in  the  body,  as  only  very  little  of  the  colour- 
ing matter  was  injected. 

The  chloroma  is  a  pale,  gi^ass,  or  brownish  green  round-celled  sarcoma, 
which,  according  to  the  observations  that  have  been  made  up  to  the  present 
time,  originates  in  the  periosteum  of  the  bones  of  the  face  and  cranium,  and 
gives  rise  to  metastatic  green  nodules  in  various  oi'gans,  especially  the  liver 
and  kidneys.  Llicke  observed  a  chloroma  of  the  testicle.  According  to 
Huber,  the  green  colour  is  due  to  small,  very  refractive  granules,  which  are 
found  in  the  cells,  and  which  give  the  micro-chemical  reaction  of  fat.  The 
chloroma  is  also  characterised  by  the  presence  of  an  abnormally  large 
amount  of  chlorine. 

"We  have  already  dwelt  sufficiently  upon  the  course  and  prognosis 
of  sarcoma  when  discussing  its  different  varieties.  The  duration  of 
the  disease  depends  in  general  upon  the  importance  of  the  organ  in- 
volved. The  sarcoma  of  the  brain  is  the  most  raj^idly  fatal,  and  may 
cause  death  in  one  and  a  half  to  two  months.  Sarcomata  of  the  medi- 
astinum are  likewise  very  malignant,  and  may  prove  fatal  in  a  few 
months  by  suffocation  or  paralysis  of  the  heart.  The  prognosis  is 
most  favourable  in  the  sarcomata  of  the  skin,  which  can  be  easily  extir- 
pated, and  of  the  extremities  in  case  the  tumours  are  removed  early 
enough  by  operative  means.  'We  have  already  mentioned  that  sarco- 
ma, especially  of  the  skin,  can  be  made  to  disappear  permanently  by 
the  inoculation  of  erysipelas.  Among  important  diagnostic  factors, 
besides  the  above-described  genei'al  characteristics  of  sarcoma,  are  its 
location  and  the  age  of  the  patient.  Its  favourite  location  is  in  mus- 
cle, periosteum,  bone,  nerves,  glands  (lymph  glands,  parotid,  testicle. 


§  129.]  THE  EPITHELIAL   TUMOURS.  807 

mamma),  and  it  not  infrequently  develops  after  an  injury.  As  regards 
age,  sarcoma  is  most  common  in  middle  life,  and  less  so  in  childhood 
and  old  age.     It  is  usually  a  painless  tumour. 

The  general  rule  for  treatment  is  to  remove  the  neoplasm  as  soon 
as  possible.  In  suitable  cases  of  encapsulated,  myelogenic  giant-celled 
sarcoma  of  bone  the  anterior  half  only  of  the  bony  capsule  may  be 
removed  by  means  of  the  hammer  and  chisel  or  the  saw.  and  the 
tumour  carefully  scraped  out  with  a  sharp  spoon.  In  sarcomata  of 
the  long  bones  the  extremity  can  usually  be  preserved,  resection  in 
continuity  being  sufficient.  In  inoperable  cases  the  inoculation  of  the 
erysipelas  toxine  may  be  tried.  Burns  has  observed  three  permanent 
cures  in  five  cases  of  this  kind,  and  Coley  published  an  account  of  nine 
cases  with  four  cures.  Among  the  latter  was  a  very  remarkable  case  of 
Bull's :  Round-celled  sarcoma  of  the  neck,  with  five  recurrences  in 
three  years ;  the  entire  removal  was  impossible  in  the  last  operation, 
and  a  wound  twelve  and  a  half  by  five  centimetres  resulted,  which 
soon  became  filled  up  with  masses  of  sarcoma  tissue.  Fourteen  days 
later  two  attacks  of  erysipelas  took  place,  whereupon  the  wound  rapidly 
cicatrised.  Seven  years  afterward  the  cure  was  found  by  Bull  and 
Coley  to  be  perfect.  Langenbuch  has  also  published  an  instance  of 
a  great  number  of  recurrent  sarcomata  of  the  skin  which  were  caused 
to  disappear  by  this  means.  One  must,  however,  constantly  bear  in 
mind  that  the  patient  may  die  as  a  result  of  the  inoculation  of  erysipe- 
las, and  hence  it  is  one's  duty  to  warn  the  patient  or  his  friends  of  the 
danger  before  this  procedure  is  adopted.  The  various  other  methods 
of  treatment  of  sarcoma  are  described  in  the  Regional  Surgery,  and  in 
connection  with  the  treatment  of  tumours  in  general.  The  treatment 
of  sarcomata  by  toxines  is  described  on  pages  778  and  779. 

§  129.  The  Epithelial  Tumours. — The  epithelial  tumours  include  the 
papilloma,  the  adenoma,  the  carcinoma,  and  the  epithelioma. 

I.  Papilloma. — The  papilloma  results  from  hyperplasia  of  the  epi- 
thelial layer  of  the  skin  and  mucous  membranes,  with  a  corresponding 
new  growth  of  connective  tissue  and  blood-vessels.  It  is  really  a  mixed 
tumour  consisting  of  newly  formed  connective  tissue  and  epithelium. 
A  distinction  is  made  between  a  hard  and  a  soft  papilloma. 

The  hard,  horny  papillomata  include,  in  the  first  place,  warts  (ver- 
rucse),  which  are  the  well-known  growths  of  the  papillae  of  the  skin 
and  epidermis,  about  the  size  of  a  bean  or  a  pea.  They  are  essentially 
a  product  of  an  overgrowth  of  the  epidermis,  which  becomes  horny. 
They  are  inoculable,  as  proved  experimentally  by  Judassohn,  and  some- 
times develop  in  great  numbers,  particularly  on  the  hands.  In  rare 
cases  a  diffuse  warty  hypertrophy  of  the  cutis  occurs — e.  g.,  on  the 


808 


TUMOURS. 


Fig.  500. — Warty  hypertro- 
phy of  the  scalp  occur- 
ring in  a  woman  twenty 
years  of  age  (Billrothj. 


I 


scalp  (Fig.  500).  Mention  should  also  be  made  of  the  onychoma 
(hypertrophy  of  the  nails),  calluses  (clavi)  resulting  from  a  circum- 
scribed hyperplasia  of  the  epidermis,  and  the 
cutaneous  horns  (cornea  cutanea),  which  are  ex- 
crescences on  the  skin  due  to  a  new  growth  of 
horny  epithelial  cells.  The  cutaneous  horns  occa- 
sionally originate  from  the  sebaceous  glands  or 
from  open  atheromata  (sebaceous  cysts).  They 
are  most  common  on  the  forehead  and  nose  in 
old  people.  Brinton  has  collected  fifteen  cases 
of  cutaneous  horn  of  the  penis,  besides  one  that 
came  under  his  own  observation.  They  some- 
times occur  in  great  numbers  (Fig.  501),  not  in- 
frequently being  curved,  and  may  attain  a  length 
of  from  twelve  to  sixteen  centimetres  or  more 
(see  Kegional  Surgery,  §  5).  It  should  be  noted  that  occasionally 
benign  cutaneous  horns  which  consist  only  of  horny  epithelial  cells 
develop  into  carcinomata. 

In  this  category  belong  also  the  tumour-lLke 
thickenings  of  the  epidermis  called  keratomata, 
which  are  most  commonly  found  on  the  sole  of 
the  foot  and  the  palm  of  the  hand,  and  are  not 
infrequently  inherited  by  all  the  branches  of  a 
family  for  many  generations  (Unna).  They  re- 
sult from  a  thickening  of  the  epidermis,  though 
the  whole  cutis  also  takes  part  in  the  hyperplasia. 
They  often  change  into  real  cutaneous  horns  or 
become  combined  with  other  new  growths  like 
angeiomata  (angeio-keratoma).  Unna  recom- 
mends for  their  treatment  the  use  of  a  ten-per- 
cent, ethereal  solution  of  salicylic  acid,  or  the 
latter  made  into  a  plaster. 

The  soft  papilloma  is  characterised  by  a  soft 
stroma,  a  marked  vascularity,  and  a  very  moder- 
ate growth  of  epithelium,  which  does  not  become 
horny.  It  occurs  on  the  skin  and  mucous  mem- 
branes— for  example,  of  the  bladder,  rectum,  and 
uterus.  The  cauliflower  excrescence  of  the  vagi- 
nal portion  of  the  cervix  is  a  soft  papilloma.  In 
the  rectum,  uterus,  and  in  other  mucous  membranes,  the  soft  papilloma 
forms  growths  which  are  analogous  to  the  above-mentioned  mucous 
polyps.     The  polyps  which  are  covered  with  epidermis,  rete  Malpighii, 


Fig.  501. — Multiple  cutane- 
ous horns,  from  twelve 
to  sixteen  centimetres  in 
length,  on  vaiious  por- 
tions of  the  body  of  a 
seventeen-year-old  girl 
(Bathge). 


§  129.] 


THE  EPITHELIAL   TUMOURS. 


809 


cutis,  and  hair,  and  occur  in  the  pharynx,  for  example,  originate,  accord- 
ing to  Arnold,  from  strayed  embryonic  cells  and  probably  belong  to 
the  teratomata.  The  soft  papillomata  not  infrequently  change  into 
sarcoma  and  carcinoma.  The  condylomata  acuminata  or  venereal 
warts  found  on  the  mucous 
membrane  of  the  vulva,  vagi- 
na, and  penis  belong  to  the 
soft  papillomata.  The  broad 
condylomata  (condylomata 
lata)  are  papillary  growths 
with  a  broad  base,  and  of- 
ten occur  about  the  anus  in 
syphilis. 

The  various  kinds  of  pap- 
illoma should  be  treated  ac- 
cording to  the  general  rules 
already  laid  down,  Warts 
should  be  removed  by  cauter- 
isation with  crude,  fuming 
nitric  acid  (not  chemically 
pure)  after  paring  off  the  epi- 
dermis with  a  knife.  They 
are  then  usually  cast  off  on 

the  fifth  or  sixth  day,  or,  if  not,  they  may  have  to  be  cauterised  again. 
Eepeated  applications  of  salicylic  or  iodoform  collodion  with  a  brush, 
as  well  as  of  a  paste  made  with  arsenic,  are  also  exceedingly  serviceable. 
By  the  use  of  these  medicaments  the  wart  gradually  drops  off  in  the 
form  of  a  dried-up  eschar.  The  same  treatment  may  be  used  for  cal- 
luses and  corns,  though  they  can  be  removed  more  simply  by  the  knife 
after  softening  them  by  salt-water  baths. 

MoUuscum  ContagiosTim  or  Epithelioma  Molluscuin.— Authorities  differ 

widely  in  their  views  as  to  the  nature  of  molluscum  contagiosum.  It  is  a 
peculiar  skin  disease  in  which  there  is  a  development  of  numerous  nodules, 
varying  in  size  from  that  of  a  pea  to  that  of  a  hazel-nut  or  larger,  generally 
located  on  the  uncovered  parts  of  the  body  and  on  the  genitals.  The  small 
tumours  are  epithelial  in  character,  and  are  said  by  Hebra  to  be  caused  by  an 
accumulation  of  cells  in  a  sebaceous  gland,  while  Virchow  thinks  the  growth 
of  epithelial  cells  begins  in  the  hair  follicles,  and  Bizzozero  in  the  interpapil- 
lary  portions  of  the  rete  Malpighii.  They  contain  characteristic  bodies,  partly 
free  and  partly  enclosed  in  cells  which  resemble  swollen  starch,  and  which, 
according  to  Leber,  are  degenerated  epithelial  cells,  although  Klebs  and  Bol- 
linger maintain  that  they  are  parasitic  (psorosperms,  coccidia).  In  its  fui'- 
ther  growth  the  molluscum  contagiosum  develops  into  a  spherical  elevation 
above  the  skin  surface,  and  may  become  pedunculated.     A  cheesy  material 


Fig, 


502. — Small  (a)  and  large  (h}  molluscum  con- 
tagiosum of  the  skin,     x  25  (Lukowsky). 


810 


TUMOURS. 


cm  be  expressed  from  the  tumour  b}-  pressure,  wliicli  probably  consists  of 
the  proliferaied  cells  of  the  rete  Malpighii  containing-  the  parasites.  The 
disease  is  contagious,  and  not  infrequently-  occurs  in  the  form  of  epidemics, 
especiall}-  in  children's  institutions.  Isolated  cases  are  rarely  met  with.  The 
nature  of  the  morphological  changes  in  the  cells  is  obscure,  and  it  is  still 
under  discussion  whether  they  are  caused  by  degeneration  or  by  parasites. 
In  my  opinion,  the  contagiousness  can  only  be  explained  on  the  parasitic 
theory.  The  treatment  consists  in  simply  pressing  out  the  small  tumours 
with  the  finger  nail ;  the  larger  ones  may  require  the  use  of  the  sharp  spoon. 
Healing  takes  place  without  the  formation  of  a  scar. 

II.  Adenoma  {Glcmdular  Tumour). — The  adenomata  corresj^ond  in 
their  structure  to  that  of  glands  (Fig.  503),  but  the  term  does  not 
include  simple  hypertrophy  of  the  latter,  being  used  to  designate  only 
the  true  new  growths  which  are  separated  from  the  surrounding  tissues 
in  the  form  of  circumscribed  nodular  tumours.  Even  adenomatous 
degeneration  of  an  entire  organ  can  be  easily  distinguished  from  a  gen- 
eral glandular  hyperplasia.  The  adenomata  form  both  hard  and  soft 
tumours.  Microscopically,  a  distinction  is  made  between  tubulous  and 
acinous  or  alveolar  adenomata.  They  are  very  often  combined  with 
the  formation  of  cysts.  The  adenoma  is  in  itself  not  malignant,  but  it 
frequently  changes  into  a  destructive  form — i.  e.,  it  becomes  a  carci- 
noma, in  that  the  growing  tubules  penetrate  the  surrounding  parts, 
-  r~--  y^-^^  t2k.%  on  an  atypical  growth,  destroy 

v\  '^'^^V^^^^jt!f^'^^^^/^#5^^=^  ^l^g  neighbouring  tissues,  and,  by  in- 
I  volving   the    lymphatics   and   blood- 

'/;  _  ^  ;-.      vessels,  give  rise  to  metastases.     The 

"  -"  ^     commencement  of  a  change  like  this 

-       from  adenoma  to  carcinoma  has  been 
\\V,    1^  called  adenoid.     There  are,  however, 

::^^r';^'.'''  .  K  ::.;::  '-^      malignant  adenomata,  which  remain 

^■^^  ;•;    •>'■  true  adenomata,  with  a  distinct  separa- 

'%h:..(^^  '-  i,  ii-       tionof  the  glandular  epithelium  from 

^  j^       the   stroma,  but   which   nevertheless 
'^-C'  -"^^        cause  local  destruction  of  tissue  and 


Y. 


Fig.  503.— Adenoma  mamm»  aiveoiare  or     ^[ive  rise  to  metastases.     The  adenoma 

acinosum.     x  30.  pi  .  ,         ,,     ,  . 

of  the  rectum  is  an  example  of  this 
variety.  The  adenoma  is  found  in  various  glandular  organs,  in  the 
skin  (sebaceous  glands,  sweat  glands),  in  the  respiratory  and  digestive 
tracts,  in  the  genital  organs,  the  mamma,  thyroid  and  salivary  glands, 
liver,  kidney,  etc. 

The  treatment  of  adenoma  consists  in  prompt  extirpation  of  the 
tumour,  as  it  is  to  be  looked  upon  as  an  early  stage  of  carcinoma,  into 
which  it  frequently  develops.     "With  reference  to  the  technique  of  the 


§  129.]  THE   EPITHELIAL   TUMOURS.  Sll 

operation  for  removal  of  adenoma  of  the  thyroid  (goitre)  and  of  lapa- 
rotomy for  removal  of  ovarian  adenoma,  particulars  will  be  found  in 
the  Regional  Surgery. 

III.  Carcinoma  (Cancer). — The  carcinoma  is  a  tumour  that  develops 
from  epithelial  and  glandular  cells,  destroys  the  normal  type  of  the 
tissue  in  the  region  primarily  affected,  is  characterised  by  unlimited 


Fig.  504. — Epithelioma  of  the  forehead  in  a  woman  fifty-six  years  old. 

growth  at  its  periphery,  by  the  formation  of  metastases  chiefly  by  way 
of  the  lymph  passages,  and  terminates  fatally,  in  the  great  majority  of 
cases,  with  symptoms  of  a  general  intoxication  (cancerous  cachexia).  It 
originates  from  the  atypical  growth  of  epithelial  cells,  the  latter  form- 
ing the  main  part  of  the  tumour,  though  every  atypical  growth  of  epi- 
thelium is  not  cancer.  In  inflammatory  processes  and  in  the  healing 
of  wounds  an  atypical  growth  of  epithelial  cells  takes  place  in  the  form 
of  cylinders  or  bulbs,  but  their  growth  is  limited,  and  they  do  not  infil- 


812 


TUMOURS. 


Fig. 


505. — Carcinoma  mammae  simplex. 
X  200. 


trate  and  destroy  the  surrounding  tissues.  It  is  quite  different  -witli 
carcinoma.  Here  the  epithelial  cells  keep  on  growing  unhindered  ;  they 
infiltrate  the  surrounding  tissues  in  the  form  of  cell  nests,  displacing 

and  destroying  them.  The  cellular 
cylinders  and  nests,  which  are  made 
up  of  proliferating  epithelial  cells, 
lie  embedded  in  a  partly  old  and 
partly  new  formed  connective-tis- 
sue stroma  (Fig.  505).  The  origin 
of  tumours,  and  particularly  of  car- 
cinoma, has  been  discussed  on  page 
TTO.  Cohnheim's  theory  was  also 
given  there.  According  to  Eibbert, 
carcinoma  begins  with  a  vigorous 
cellular  proliferation  of  the  subepi- 
thelial connective  tissue,  and  not 
with  a  primary  advance  of  the  epi- 
thelium into  the  connective  tissue.  Ribbert  claims  that  in  some  of  the 
cases  the  subepithelial  inflammation  of  the  connective  tissue  is  tuber- 
cular in  nature.  The  growth  of  subepithelial  connective  tissue  into 
the  epithelium  causes  the  epithelial  cells  to  become  separated  from  their 
organic  connections,  and  to  be  displaced  into  the  cellular  connective 
tissue,  where  they  can  take  on  an  inde- 
pendent gro*svth.  It  is  this  separation  of 
epithelial  cells  from  their  normal  connec- 
tions and  their  displacement  among  prolif- 
erating connective  tissue  that  constitutes, 
according  to  Ribbert,  the  real  nature  of 
carcinoma  formation.  This  theory  is  ap- 
plicable to  a  certain  number  of  carcinomata, 
but  not  to  all  (Ilauser).  The  mode  of 
origin  of  carcinoma  is  certainly  not  always 
the  same  ;  the  tissue  changes  may  start  first 
in  the  epithelium  or  in  the  connective  tis- 
sue, depending  upon  which  of  these  is  acted 
upon  by  the  morbid  process.  But,  wher- 
ever it  begins,  the  final  result  in  carcinoma 
is  always  the  same,  and  consists  chiefly  in 
a  fundamental  alteration  in  the  biological  properties  of  the  epithelial 
cells,  so  that  they  take  on  parasitic  characteristics.  The  carcinoma  cell 
has  become  a  different  one  morphologically  and  biologically  from  the 
mother  cell  from  which  it  was  derived.     The  real  nature  of  these 


Fig.  oijij. — Section  througli  a  com- 
mencing embolic  cancer  in  a 
liver  capillary  resulting  from  an 
adeno-earcinoma  of  the  stomach 
(Ziegler).     x  300. 


§129.]  THE   EPITHELIAL   TUMOURS.  813 

degenerative  changes  is  still  unknown.  Of  late  attempts  have  been 
made  to  establish  the  raicrobic  origin  of  carcinoma  (see  page  819,  ff). 
As  a  result  of  the  unimpeded  growth  of  the  carcinoma,  or  rather  of 
the  groups  of  e23ithelial  cells,  the  latter  invade  the  Ijmph  and  blood- 
vessels and  produce,  by  means  of  transported  living  cancer  cells,  sec- 
ondary nodules  in  the  nearest  lymph  glands,  and  later  in  the  various 
internal  organs  (Fig.  506).  This  power  of  forming  metastases — in 
other  words,  of  causing  a  general  infection  of  the  body — is  character- 
istic of  cancer.  As  regards  the  development  of  metastases  in  the  lymph 
glands,  it  has  been  shown  that  the  epithelial  cells  which  make  their 
way  through  the  afferent  lymphatics  into  the  lymph  sinuses  multiply 
by  caryocinesis ;  that  they,  by  their  continuous  growth,  mechanically 
displace  the  glandular  tissue ;  and  that  endothelial  cells  and  lymph 
cells  do  not  change  into  cancer  cells.  Before  the  appearance  of  the 
metastatic  elements  the  lymph  glands  are  usually  in  a  condition  of 
inflammatory  hyperplasia.  The  metastases  may  be  especially  numerous 
if  a  carcinoma  breaks  through  directly  into  a  large  vein  and  carcinoma 
cells  are  carried  through  the  circulation.  Goldmann  has  shown  that 
this  occurs  more  often  than  has  hitherto  been  supposed. 

Thiersch  was  the  first  to  prove  the  epithelial  origin  of  cutaneous 
carcinomata,  and  Waldeyer  afterwards  furnished  the  same  proof  for 
carcinomata  of  the  various  organs.  Other  authorities — e.  g.,  Klebs, 
Gussenbauer,  and  Eindfleisch — still  hold  -with  \^irchow  to  the  earlier 
view,  that  the  carcinoma  cells  can  also  originate  from  connective-tissue 
cells,  particularly  from  endothelia.  Klebs  has  recently  expressed  his 
views  regarding  this  question  by  saying  that  the  connective-tissue  cells 
and  other  cells — e.  g.,  the  elements  of  striated  muscular  fibres — in  con- 
sequence of  "  epithelial  infection  "  by  the  carcinoma  cells  derived  from 
the  pre-existing  ej)ithelia,  become  epithelioid  carcinoma  cells,  ^e 
have  already  said,  in  discussing  sarcoma,  that  alveolar  sarcomata  are 
sometimes  difiicult  to  differentiate  from  carcinomata  anatomically,  and 
that  many  endotheliomata  run  a  similar  clinical  course  to  carcinomata. 

In  the  skin  the  carcinoma  arises  from  the  cells  of  the  rete  Mal- 
pighii  or  from  the  cutaneous  glands ;  an  infiltration  of  the  corium  with 
epithelial  cells  gradually  takes  place,  the  cells  being  collected  in  single 
groups,  cylinders,  or  nests  which  lie  in  a  partly  old  and  partly  new 
formed  connective-tissue  stroma.  In  the  glands  a  proliferation  of  the 
glandular  epithelium  first  takes  place,  forming  an  adenoma ;  then  these 
proliferated  cells  invade  the  tissue  surrounding  the  lobes  of  the  glands, 
where  they  continue  to  grow  unimpeded.  The  shape  of  the  proliferated 
epithelial  or  cancer  cells  is  not  constant,  but  depends  upon  the  location 
of  the  cancer.     The  cells  of  an  epithelioma  of  the  skin  correspond  in 


su 


TUMOCTRS. 


general  to  those  of  the  rete  Malpigliii,  wliile  in  a  carcinoma  of  the 
stomach  they  have  a  cylindrical  form,  etc.  lietrograde  metamorphoses 
are  very  common  in  carcinoma  because  the  nutrition  of  the  great  num- 
bers of  cancer  cells  is  insufficient.  Hence  fatty,  mucoid,  colloid,  or 
cystic  degeneration  as  well  as  calcification  are  of  frequent  occurrence. 
Psammocarcinomata  of  the  ovary  and  mammary  gland  have  been 
described — i.  e.,  carcinomata  with  degeneration  products   resembling 


Fig.  5u7.— Larire  ulceratintr  carcinoma  of  the 
lo^^  er  jaw  and  cheek  occurring  in  a  patient 
suffering  from  lupus  (Esmarchj. 


Fig.  508 — Pronounced  destiuetinn  of  the 
face  bj  an  epithehoma  of  the  skin  (Bill- 
roth).' 


grains  of  sand,  which  are  scattered  through  the  tumour  in  a  definite 
way.  The  degenerative  changes  in  the  central  portions  of  a  carcinoma 
and  the  adhesion  to  the  integument  often  give  rise  to  an  umbilicated 
drawing  in  or  depression  of  the  skin.  Superficial  carcinomata,  espe- 
cially those  which  involve  the  skin,  mucous  membranes,  or  mamma,  are 
extremely  apt  to  break  down  and  form  extensive  sloughing,  punched- 
out  ulcers  (Figs.  507,  508).  Bleeding  not  infrequently  takes  place, 
manifesting  itself  in  the  form  of  circumscribed  haemorrhages  or  blood 
cvsts,  or,  in  other  cases,  a  carcinoma  may  by  degrees  erode  a  large 
vessel,  and  thus  suddenly  lead  to  a  profuse  loss  of  blood,  which  may 
prove  fatal. 

Occasionally  a  primary  carcinoma  is  found  in  a  multiple  form. 
Schimmelbusch  has  collected  these  rare  cases  from  literature  showing 
that  multiple  carcinomata  of  the  skin  are  the  most  common,  and  may 
develop  from  a  soot  or  tar  eczema,  from  senile  seborrhoea  and  xero- 
derma pigmentosum,  ulcer  of  the  leg,  etc.  The  multiplicity  of  carci- 
nomata results  from  the  multiplicity  of  the  irritations  and  of  the 
embrvonic  starting  points  of  tumour  (Walter).     Kegarding  the  devel- 


§  129.]  THE  EPITHELIAL   TUMOURS.  815 

opment  of  multiple  carcinoniata  by  inoculation  or  implantation  from 
one  part  of  the  body  to  another,  see  page  820. 

The  following  different  varieties  of  carcinoma  can  be  distinguished  : 

1.  Flat  Epithelial  Cancer  or  Epithelioma. — The  epithelioma  of  the  skin, 
or  cancroid,  appears  in  the  form  of  diffuse  thickenings  or  nodular,  warty,  often 
ulcerating-,  elevations.  On  section,  the  alveolar  structure  can  usually  be  seen 
with  the  naked  eye  and  the  epithelial  nests  or  cylinders  can  be  squeezed  out 
or  scraped  from  the  cut  surface  with  the  knife.  Some  epitheliomata  remain 
superficial,  while  others  grow  into  the  deeper  parts.  The  superficial  variety, 
ulcus  rodens,  as  it  used  to  be  called,  arises  mainly  from  the  rete  Malpighii, 
while  the  growth  having  deeper  attachments  takes  its  origin  to  a  greater 
extent  from  the  sebaceous  glands. 

Epitheliomata  also  develop  on  mucous  membranes  that  have  a  pavement 
epithelium  (mouth,  pharynx,  oesophagus,  vagina,  uterus,  bladder). 

2.  Cylindrical-celled  Carcinoma. — The  carcinoma  with  cylindrical  cells  is 
found  particularly  in  the  mucous  membrane  of  the  digestive  tract  and  uterus  ; 
it  has  a  soft  consistence  and  is  very  likely  to  undergo  a  mucoid  degeneration. 

3.  Carcinoma  with  Gland  Cells  {Carcinoma  Glandulare). — This  is  found 
in  various  glandular  organs  (mamma,  liver,  salivary  glands,  kidneys,  testicles, 
etc.),  and  varies  histologically  according  to  the  organ  affected. 

■i.  Other  Varieties  of  Carcinoma. — According  to  the  shape,  consistence, 
and  other  properties  of  the  cancer  the  following  varieties  may  be  differen- 
tiated. The  scirrhus  is  a  very  hard,  tough  carcinoma  with  small  and  few 
cancer-cell  nests  lying  in  a  dense  stroma.  The  soft  carcinoma  (carcinoma 
medullare)  is  the  opposite  of  the  scirrhus,  being  rich  in  cells  and  having  a 
soft  stroma.  The  pigmented  or  melano-carcinoma,  like  the  melano-sarcoma, 
is  a  brown  or  black  tumour,  which  is,  however,  much  less  common  than  the 
latter.     The  pigment  is  likewise  situated  in  the  cells. 

The  so-called  giant-celled  carcinoma  is  in  some  instances  made  up  of  true 
giant  cells,  while  in  others  the  increase  in  the  size  of  the  cells  is  due  to 
mucoid  or  dropsical  degeneration. 

The  colloid  cancer  (carcinoma  gelatinosum)  occurs  especially  in  the  intes- 
tine and  breast,  where  it  forms  a  transparent  gelatinous  tumour  as  a  result 
of  the  mucoid  or  gelatinous  degeneration  of  the  cell 
nests.  The  carcinoma  myxomatodes  originates  either 
from  the  mucoid  degeneration  of  the  stroma  and  often 
of  the  cancer  cells,  or  from  the  combination  of  a  myx- 
oma with  a  carcinoma  (myxo-carcinoma).  Occasion- 
ally colloid  degeneration  of  the  cancer  cells  gives  rise 
to  homogeneous  spherical  bodies  which  are  found  in 
the  cancer  nests.     Psammocarcinoma  is  spoken  of  on 

page  805.  ^  ^  ^^^  509.— Epithelioma  of 

The  external  appearance  of  carcinoma  is  variable.  the  lower  lip  in  a  man 
It  sometimes  forms  circumscribed  nodules  and  warty  ■  IJ^j^^q  °_  "^  Kecovlry^'^' 
elevations,  as  in  Fig.  509,  sometimes  more  diffuse,  su- 
perficial infiltrations  and  indurations,  or  ulcers  with  hard,  thickened,  and 
infiltrated  edges  (Figs.  507,  508,  510),  or,  finally,  papillary  cauliflower-like 
growths  (Fig.   511),  particularly  on  the  mucous  membranes— e.  g.,  on  the 


816 


TUMOURS. 


bladder,  etc.  Occasionally  the  skin,  as  in  the  region  of  the  mamma,  becomes 
ditfu.sely  diseased,  as  hard  as  a  board,  and  iufiltx'ated  by  a  great  number  of 
small  and  large  nodules  (cancer  en  cuirasse). 

Etiology  of  Carcinoma. — Local  irritations  of  a  mechanical  and  chem- 
ical character  are  very  important  factors  in  the  production  of  a  car- 
cinoma. Hence  one  is  most  likely  to  develop  in  those  parts  of  the  body 
where  mechanical  and  chemical  irritations  commonly  occur,  as  in  the 
skin,  lips,  month,  oesophagus,  and  in  other  parts  of  the  digestive  tract 
where  normally  narrow  jjlaces  exist,  such  as,  for  example,  the  oesopha- 
gus at  the  point  where  it  passes  through  the  diaphragm,  the  cardiac 
and  pyloric  regions  of  the  stomach,  the  sigmoid  flexure,  the  rectum  near 
the  sphincter  tertius,  and  the  anus.  In  men,  cancers  of  the  skin,  lips 
(almost  always  the  lower  lip),  mouth,  and  rectum  are  the  most  com- 
mon ;  while  in  women  the  glandular  carcinomata  predominate,  and 
those  of  the  mamma  and  the  uterus  are  especially  frequent.  This  latter 
fact  explains  why  carcinomata  occur  more  frequently  in  the  female  sex 
than  in  the  male.  Out  of  7,878  cases  of  carcinoma,  2,861  occurred  in 
males  and  5,017  in  females.  Carcinoma  of  the  stomach  is  equally 
common  in  women  and  men,  and  is  very  likely  to  develop  from   a 


Fig.  510. — Epithelioma  in  a  man  fifty-eight 
years  of  age.    Duration  ten  years. 


Fig.  .511. — Papillary  epithelioma  of  the  left 
cheek,  starting' in  the  mucous  membrane 
of  the  cheek. 


cicatrised  gastric  ulcer.  The  epitheliomata  of  the  lips,  especially  the 
lower  lip  in  men,  having  been  ascribed  to  smoking,  to  frequent  irrita- 
tion from  unskilful  shaving,  etc.,  and  the  epitheliomata  of  the  tongue 
and  mucous  membrane  of  the  inside  of  the  mouth  to  the  irritation  pro- 
duced by  smoking,  chewing  tobacco,  and  drinking,  or  by  the  shai-p 
edges  of  the  teeth.     Out  of  77  carcinomata  of  the  lip,  73  occurred  in 


§  129.] 


THE   EPITHELIAL   TUMOURS. 


81T 


men  and  4  in  women,  and  three  out  of  the  four  women  were  smokers 
(Warren).  Out  of  245  cases  of  carcinoma  of  the  tongue,  230  were 
males  (Pennel,  Sachs,  Bottini).  The  100  cases  observed  by  Bottini  all 
occurred  in  individuals  who  were  very  much 
given  to  the  use  of  tobacco,  including  three 
women.  Chewing  has  been  seen  to  cause 
carcinoma  of  the  mucous  membrane  of  the 
cheek  and  gum  in  the  vicinity  of  the  last 
molar  teeth  even  in  young  subjects.  Tobac- 
co in  its  natural  form  does  not  appear  to 
be  injurious,  but  rather  the  substances 
which  are  used  in  the  tobacco  factories  for 
adulterating  it.  The  epitheliomata  of  the 
scrotum,  observed  in  chimney-sweeps  and 
workers  in  tar  and  paraffin,  are  exj)lainable 
on  the  same  principle.  Analogous  irritat- 
ing chemical  substances  are  present  in  soot, 
tar,  and  paraffin,  just  as  in  tobacco-smoke, 
tobacco-juice,  and  tobacco-ashes — i.  e.,  va- 
rious products  of  dry  distillation,  especially 
tar,  carbonate  and  acetate  of  ammonium, 
pure  acetic  acid,  and  carbolic  acid.  These 
irritating  substances  become  deposited  in 
the  skin  of  the  scrotum,  and  sometimes  give 
rise  to  cancer.  I  observed  in  a  worker  in 
paraffin  who  had  a  characteristic  chronic 
paraffin  dermatitis,  with  the  formation  of 
scabs  and  pustules  on  the  hands  and  fore- 
arms, the  development  of  a  typical  car- 
cinoma with  metastases  at  the  site  of  one 
of  the  scabs.     Fig.  512  shows  the  hand  of 

this  patient,  who  finally  died  of  general  carcinosis.  Two  years  pre- 
viously I  had  removed  from  the  same  man  a  paraffin  epithelioma  of 
the  scrotum,  which  did  not  recur.  Characteristic  examples  of  the 
development  of  carcinoma  from  chemical  and  in  part  traumatic  irri- 
tations are  the  carcinoma  of  the  penis,  which  occurs  almost  exclusively 
in  case  of  a  tight  foreskin  (phimosis),  and  the  primary  carcinoma  of  the 
gall-bladder  in  case  of  gall-stones.  Chronic  inflammations  in  various 
parts  of  the  body  often  give  rise  to  carcinoma — e.  g.,  ulcers,  fistulse, 
sequestrum  cavities,  syphilitic  and  tubercular  processes,  etc.  Carcino- 
ma also  develops  in  benign  tumours — e.  g.,  in  warts,  sebaceous  glands, 
cutaneous  horns,  etc.  In  some  cases  a  single  traumatism  (blow,  kick, 
55 


Fig.  .o12. — Hand  of  a  worker  in  par- 
artin,  showing  chronic  derma- 
titis with  a  formation  of  pus- 
tules and  crusts  and  papillary 
growths  ;  carcinoma  of  the  fore- 
arm starting  from  one  of  these 
inflamed  spots ;  amputation  of 
the  forearm  and  death  from  gen- 
eral carcinosis. 


818  TUMOURS. 

etc.)  or  cicatrix  is  a  sufficient  predisposing  factor  to  produce  a  car- 
cinoma. The  carcinomata  that  form  in  cicatrices  probably  develop 
from  epitheUal  cells  inclosed  in  the  scar.  According  to  diiferent 
authors,  the  development  of  carcinoma  is  favoured  by  a  too  plentiful 
meat  diet,  as  the  inhabitants  of  southern  countries,  who  live  largely  on 
veo;etal)le  food,  and  the  herl)ivorous  animals,  are  said,  as  compared  with 
the  cai-nivora,  to  suffer  very  seldom  from  this  disease.  A  predisposi- 
tion to  carcinoma  often  appears  to  be  inherited.  There  are  numerous 
very  striking  examples  which  prove  the  heredity  of  carcinoma.  I  need 
only  mention  the  Napoleon  family,  and  the  instance  reported  by  Broca, 
in  which,  out  of  26  descendants  (over  30  years  of  age)  of  a  woman  who 
died  of  carcinoma  of  the  breast,  15  developed  carcinoma.  It  is  essen- 
tially a  disease  of  advanced  life.  At  this  period  a  slowly  increasing 
atrophy  of  the  stroma,  in  a  certain  sense,  takes  place,  with  degeneration 
of  the  elastic  fibres,  causing  tlie  skin,  for  instance,  to  become  shrivelled 
and  thin,  and  rendering  it  easier  for  the  epithelium  to  make  its  way 
into  the  stroma  as  a  result  of  mechanical  or  chemical  irritations.  A 
"  boundary  war,"  as  it  were,  begins  between  epithelium  and  connect- 
ive tissue,  whicli  in  carcinoma  ends  in  a  victorious  entrance  of  the 
epitheHum  into  the  less  resistant  stroma.  The  highest  mortality  of  car- 
cinoma occurs  between  fifty-five  and  sixty-five.  It  is  interesting  to 
note  that  white  people  are  twice  as  often  attacked  by  carcinoma  as  col- 
ored. Social  conditions  are  also  of  importance  in  the  origin  of  carcino- 
ma. It  is  more  common  among  the  higher  classes  and  among  country 
people  than  among  the  poor  and  those  who  live  in  industrial  centres 
(ft.  Williams).  With  the  improvement  in  the  condition  of  the  people 
in  England  the  malignant  tumours  (carcinoma,  sarcoma)  have  become 
more  common,  and  the  mortality  rate  is  at  present  four  times  larger 
than  it  was  fifty  years  ago  (Williams).  Among  vegetarians — e.  g.,  in 
India — carcinoma  is  rarer  than  among  the  population  in  England,  where 
meat  is  usually  eaten.  The  statistics  of  Nason  show  that  carcinoma  has 
increased  of  late,  particularly  in  swampy  regions  with  stagnant  water, 
and  he  considers  it  possible  that  the  evaporation  of  stagnant  water  or 
soft  ground  causes  infection  just  as  in  the  case  of  malaria  (see  page 
819,  Importance  of  Micro-organisms  in  the  Etiology  of  Carcinoma). 

What  is  the  cause  of  the  unlimited  energy  and  power  of  growth 
possessed  by  carcinoma  ?  Hansemann  attempted  to  answer  this  ques- 
tion in  the  following  way :  While  it  is  an  established  fact  under 
normal  conditions  that  in  the  indirect  nuclear  division  the  chromatin 
or  nuclear  fibrils  divide  into  exactly  equal-sized  groups,  in  malignant 
epithelial  tumours  (carcinoma)  a  division  often  takes  place  into  two 
unequal  groups.     This  asymmetrical  nuclear  division,  which  belongs 


129.] 


THE  EPITHELIAL   TUMOURS. 


819 


only  to  the  malignant  epithelial  growths,  is  due  to  the  fact  that  the  cell 
eliminates  certain  parts  of  its  protoplasm  in  the  same  way  that  the 
ovum,  by  expelling  the  directing  or  polar  globules,  frees  itself  of  cer- 
tain elements  that  are  present  in  too  large  quantities.  In  this  way  the 
cancer  cells  attain  an  independence  like  that  of  the  ovum,  and  to  this 
is  due  their  energy  of  growth  and  power  of  further  development  as 
metastases  in  different  parts  of  the  body. 

Importance  of  Micro-organisms  in  the  Etiology  of  Carcinoma. — In  recent 
times  the  attempt  has  been  repeatedly  made  to  establish  the  microbic  theory 
of  the  origin  of  carcinoma.  Bacteria  have  frequently  been  found  in  carci- 
nomata,  and  Scheuerlen,  in  particu- 
lar, believed  that  he  had  found  the 
bacillus  of  carcinoma,  which  was 
afterwards  proved  to  be  a  harmless 
saj)roph  y  te.  Besides  harmless  sapro- 
phytes, the  bacteria  of  inflamma- 
tion and  suppui'ation  (staphylococci, 
streptococci,  and  bacilli)  are  occa- 
sionally found  in  malignant  tu- 
mours, particularly  in  degenerated 
portions.  These  bacteria  are  of  no 
importance  in  the  origin  of  carcino- 
ma, but  they  sometimes  give  rise  to 
suppuration  and  even  septic  infec- 
tion. Numerous  bacteriological  in- 
vestigations show  that  micro-organ- 
isms (bacteria,  fungi,  etc.)  may  be 
dejDOsited  in  tumours,  even  though 
the  latter  ai'e  not  in  direct  contact 
with  the  external  air. 

At  present  the  parasitic  .theory 
of  the  origin  of  carcinoma  (by  pro- 
tozoa) is  attracting  universal  interest. 
The  protozoa  have  already  been  de- 
scribed as  the  causes  of  vegetable  and 
animal  diseases  (page  282).  Darier 
and  Thoma  in  1889  discovered,  inde- 
pendently of  one  another,  certain  parasitic  organisms  in  the  epithelial  cells 
of  carcinomata  of  the  stomach,  rectum,  and  breast  (Fig.  513).  Darier  classi- 
fied these  as  sporozoa  (psorosperms).  These  doubtful  bod.ies  are  unicellular 
organisms,  4  to  15  micromillimetres  in  diameter,  consisting  of  protoplasm 
and  a  nucleus.  They  occur  singly  or  in  groups  of  four  to  six  within  the 
nuclei.  They  can  be  stained  by  the  usual  methods.  The  original  reports  of 
Darier  and  Thoma  have  been  followed  by  numerous  other  confirmatory 
reports  of  different  authorities.  Some  of  these  regard  the  organisms  in  ques- 
tion as  sporozoa,  and  as  the  exciting  cause  of  carcinoma ;  others  believe  only 
the  former,  and  doubt  their  etiological  connection  with  carcinoma.     A  third 


a 

Fig.  513. — Epithelial  cells  of  a  cylindrical-celled 
carcinoma  of  the  rectum  containing  ajiparent 
parasitic  bodies.  The  upper  figure,  which  is 
magnified  910  times,  shows  epithelium  con- 
taining a  wandering  cell  with  two  nuclei  and 
nine  large  nuclei ;  at  P  are  seen  the  three 
intracellular,  probably  parasitic,  .structures ; 
a-d,  show  the  bodies  in  question  under  high 
power  (1,500) ;  e  represents  a  larger  structui'e 
of  probably  the  same  nature. 


820  TUMOURS. 

category  of  authorities  are  in  doubt  about  the  matter,  and  others  finally 
explain  the  bodies  as  mainly  degeneration  products  of  the  cells  or  nuclei. 
According  to  Adamkiewicz  and  Pfeiffer,  the  carcinoma  cells  are  partly  para- 
sitic structures — i.  e.,  proliferated  sporozoa  (coccidiaj — and  partly  proliferated 
epithelial  cells  resulting  from  the  toxic  action  of  the  protozoa. 

In  my  opinion,  the  sporozoa  have  not  yet  been  proved  to  be  the  cause  of 
carcinoma,  and  it  has  not  been  possible  to  isolate  the  parasites  in  question 
and  by  the  inoculation  of  pure  cultures  to  produce  carcinoma.  It  may  be  said 
in  reply  that  the  plasm odia  of  malaria  have  also  not  been  obtained  in  pure 
cultures  nor  successfully  inoculated  upon  man,  but  yet  no  one  doubts  that 
they  are  parasites  and  the  cause  of  malaria.  The  coccidia  are  very  sensitive 
bodies,  very  hard  to  inoculate  upon  animals,  and  it  seems  that  each  species 
can  act  as  a  parasite  only  in  certain  cells  of  a  certain  species  of  animal 
(Metschnikoff).  The  very  interesting  investigations  of  Jiirgens,  mentioned 
on  page  806,  must  be  regarded  as  having  an  important  bearing  upon  the 
parasitic  theory  of  the  etiology  of  malignant  tumours,  particularly'  sarcoma, 
and  also  of  carcinoma. 

The  transmissibility  of  carcinoma  has  been  proved  by  experimental  and 
clinical  observations,  but  this  cannot  be  taken  as  a  proof  of  its  pai'asitic 
natui'e.  Apart  from  the  auto-inoculation  observed  in  patients  with  carcinoma, 
the  transmissibility  from  man  to  man,  or  from  animal  to  animal  of  the  same 
species,  has  succeeded  only  in  exceptional  cases.  The  inoculation  of  animals 
with  human  carcinoma,  or  of  one  species  of  animal  Avith  a  carcinoma  from 
another,  has  not  jet  been  accomplished.  The  successful  attempts  at  inocula- 
tion of  animals  of  the  same  species  have  been,  when  compared  with  the  fre- 
quent failures,  very  few.  Novinsky  and  Weber  made  successful  inocula- 
tions in  dogs,  Hanan  in  rats,  and  Moran  in  mice.  The  latter  continued  his 
inoculations  through  several  generations  for  five  years,  and  it  was  found  that 
"with  each  succeeding  generation  the  carcinoma  became  gradually  hai'der  to 
inoculate  and  less  malignant.  It  is  not  at  all  rare  for  a  carcinoma  to  infect 
another  part  of  the  body  by  contact — e.  g.,  a  cancer  of  the  lower  lip  may 
attack  the  upper  lip,  one  of  the  tongue  may  be  inoculated  upon  the  mucous 
membrane  of  the  cheek,  and  a  carcinoma  of  the  stomach  may  grow  through 
the  serous  membrane  and  involve  organs  in  the  peritoneal  cavity.  The 
inoculation  of  tumour  cells  may  also  occur  during  operations— e.  g.,  by 
means  of  the  instruments  or  the  hands  of  the  operator.  The  patient  can 
also  infect  himself  by  carrying  the  tumour  cells  from  a  carcinoma  to  another 
part  of  the  body  by  means  of  the  hands.  In  a  similar  way  carcinoma  of  the 
upper  air-passages  may  give  rise  to  carcinoma  of  the  bronchi  and  lungs  by 
aspiration,  and  carcinoma  of  the  buccal  cavity  and  oesophagus  to  carcinoma 
of  the  stomach,  etc.  In  all  these  cases  the  inoculation  of  the  primary  car- 
cinoma is  proved  by  the  fact  that  the  secondary  tumour  possesses  exactly  the 
same  structure  as  the  original  one — e.  g.,  a  squamous-celled  epithelioma  of 
the  tongue  gives  rise  to  a  carcinoma  of  the  same  anatomical  .structure  in  the 
stomach.  Hahn  reported  successful  cases  of  inoculation  of  a  carcinoma  of 
one  breast  upon  the  other  breast.  The  fact  that  carcinoma  is  so  frequently 
and  easily  inoculated  upon  another  portion  of  the  body  in  individuals 
already  suffering  from  the  disease  would  seem  to  show  that  the  success  of 
inoculation  depends   upon  a  special   predisposition  on  the  pai^t  of   the  re- 


§129.]  THE   EPITHELIAL   TUMOURS.  821 

cipient;  this  predisposition  is  present  in  individuals  having-  carcinoma.  The 
rarity  of  successful  inoculation  of  carcinoma  from  one  animal  to  another  of 
the  same  species  shows  that  the  inoculation  of  healthy  individuals  by  those 
suflPering  from  the  disease  only  occurs  in  exceptional  cases. 

Carcinoma  can  thus  be  said  not  to  belong  to  the  contagious  diseases  in 
the  usual  sense.  Contagion  is  possible,  as,  for  example,  in  the  case  of  wives 
with  carcinoma  of  the  uterus  who  give  their  husbands  a  carcinoma  of  the 
penis ;  but  it  really  belongs  to  the  rarest  exceptions. 

The  successful  inoculations  of  carcinoma  cannot,  as  has  been  said,  be 
used  as  proof  of  the  parasitic  origin  of  carcinoma.  They  merely  have  the 
importance  of  a  successful  transplantation  of  tissue. 

Although  the  parasitic  theory  of  carcinoma  has  not  yet  been  proved, 
it  must  nevertheless  be  said  that  there  is,  a  priori,  no  decisive  ground 
against  the  acceptance  of  the  same.  On  the  contrary,  since  the  recent  inves- 
tigations of  Jlirgens  (page  806)  regarding  the  parasitic  origin  of  sarcoma,  I 
consider  the  theory  very  probable  ;  but  whether  it  is  applicable  to  every  case 
of  carcinoma  it  would  be  impossible  to  say.  The  etiology  of  carcinoma  is 
probably  not  a  simple  one,  and  doubtless  various  factors  enter  into  it.  For 
the  further  investigation  of  the  etiology  of  carcinoma  it  is  advisable  to 
examine  portions  of  living  tumour  material  with  a  beatable  microscope. 
Under  such  a  microscope  peculiar  movements  have  been  observed  in  the 
interior  of  the  carcinoma  cells. 

Course,  Prognosis,  and  Diagnosis  of  Carcinoma. — Carcinoma  runs  a 
chronic  course  extending  over  months  and  years.  Its  varying  energy 
of  growth  and  its  location  are  factors  of  great  importance  in  determin- 
ing how  rapidly  or  slowly  the  disease  will  progress.  In  rare  instances 
a  more  or  less  acute  general  carcinosis  takes  place,  causing,  in  a  few 
weeks,  metastases  and  marked  cancerous  cachexia.  The  latter  is  very 
much  increased  by  rapid  growth  of  the  primary  and  secondary  cancer 
nodules,  by  ulceration  and  sloughing,  by  stenoses, that  interfere  with 
the  entrance  of  air  or  food,  by  disturbances  of  digestion,  etc.  Ulcera- 
tion is  especially  prominent  in  epitheliomata  of  the  skin.  Cancerous 
ulcers  are,  as  a  rule,  irregular  in  form,  and  their  edges  and  bases,  as 
well  as  the  surrounding  tissue,  are  hard  and  indurated.  The  superficial 
ulcerating  epithelioma  of  the  skin,  the  so-called  ulcus  rodens,  runs  com- 
paratively the  most  favourable  course,  in  that  it  spreads  slowly  over  the 
surface,  has  less  tendency  to  involve  the  deeper  parts,  and  only  leads 
late  in  its  course  to  infection  of  the  nearest  lymph  glands.  Carcinoma 
spreads  chiefly  by  way  of  the  lymphatics  ;  the  nearest  lymph  glands 
become  afiected  first.  Embolic  metastases  caused  by  the  breaking- 
through  of  a  primary  or  secondary  carcinoma  into  the  circulation  with 
general  carcinosis  are  rarer,  while  in  sarcoma  they  are  the  rule. 

As  regards  the  development  of  metastatic  tumours,  the  condition  of 
the  tissue  in  which  the  carcinoma  cells  lodge  is  important.    The  differ- 


822  TUMOURS. 

eiit  tissues  and  organs  possess  a  variable  predisposition  for  the  furtlier 
growth  of  the  carcinomatous  emboli.  It  is  only  in  this  way  that  one 
can  understand  why  it  is  that  metastases  sometimes  develop  only  in 
tlie  bones,  and  that  metastases  are  very  rare  in  the  spleen.  Embolic 
metastases  are  observed  most  frequently  in  the  liver  in  case  of  carcinom- 
ata  of  the  regions  connected  with  the  jDortal  system,  and  then  in  the 
lungs,  kidney,  and  bone.  The  order  of  frequency  in  the  location  of 
secondary  carcinomatous  nodules  is  as  follows  :  lymph  glands,  liver, 
lungs,  pleura,  peritonaeum,  kidney,  bone,  spleen.  Metastases  in  bone 
are  frequently  observed  in  the  case  of  carcinomata  of  the  vascular 
thyroid  gland  in  consequence  of  a  breaking  through  of  the  carcinoma 
into  the  circulation,  and  also  in  carcinoma  of  the  testicle,  prostate,  and 
mammary  gland.  Of  50  carcinomata  of  the  thyroid  gland,  Hinterstois- 
ser  found  that  10  were  associated  with  metastases  in  the  bones,  and  of 
20  cases  Paget  also  found  the  same  thing  true  of  10.  On  the  other 
hand,  Gussenbauer  and  Winiwarter  state  that  in  903  cases  of  carcinoma 
of  the  stomach,  metastases  were  not  found  once  in  the  bones,  if  we 
except  the  cases  of  general  carcinosis.  The  rarity  of  metastases  in  the 
spleen  is  striking  when  we  consider  that  pyseraic  abscesses  of  this  organ 
are  so  common.  Out  of  753  autopsies  on  carcinoma  of  the  mammary 
gland  there  were  metastases  in  the  liver  241  times,  and  in  the  spleen 
only  17  times. 

According  to  Klemperer,  the  metabolism  of  cancerous  individuals 
is  characterised  by  a  pronounced  destruction  of  albumen,  the  viscera 
undergoing  fatty  degeneration,  and  the  blood  showing  a  marked  diminu- 
tion in  its  percentage  of  carbonic  acid  almost  down  to  one  third  of  the 
normal.  According  to  Grawitz  and  others,  all  the  constituents  of  the 
blood  are  diminished  in  carcinoma.  The  carcinoma  leads  to  a  general 
intoxication  by  certain  poisonous  substances  (toxines).  The  excretion 
of  urea  diminishes,  as  in  all  malignant  tumours,  and  finally  becomes  less 
than  twelve  grammes  a  day  (Rommelaire,  Eansier).  According  to 
Miiller,  the  cancerous  cachexia  resulting  from  the  increased  destruc- 
tion of  albumen  is  similar  to  that  occurring  in  the  febrile  diseases  and 
in  long-continued  malaria,  leucseraia,  and  pernicious  anaemia.  The 
cause  of  the  abnormal  destruction  of  albumen  in  cancerous  individu- 
als probably  lies  in  the  poisonous  action  of  the  products  of  metabolism 
of  the  carcinoma.  As  a  result  of  the  accumulation  of  these  products 
of  metabolism  and  of  the  insufiiciency  of  the  kidneys,  coma  and  death 
may  supervene  (see  pages  743,  744). 

The  prognosis  of  cancer  is,  as  we  have  already  clearly  stated,  very  un- 
favourable. Complete  cures  are  rare,  even  when  the  carcinomata  are  extir- 
pated very  early  in  their  course.     As  a  rule,  one  x'ecurrence  follows  another 


§129.]  THE   EPITHELIAL   TUMOURS.  823 

until  the  patient  succumbs  to  general  carcinosis  or  exhaustioii.  We  make 
a  distinction,  based  upon  their  mode  of  origin,  between  continuous  and 
regional  recurrences  ;  the  former  spring  from  portions  of  the  primary  tumour 
which  were  left  behind  at  the  time  of  the  operation,  while  the  latter  (regional 
recurrences)  are  to  be  looked  upon  as  independent  new  tumours  in  the  cica- 
trix or  its  vicinity.  The  second  kind  sometimes  make  their  appearance  only 
after  the  lapse  of  years.  All  recurrences  which  occur  later  than  two  years 
after  the  operation  should  be  considered,  according  to  Snow,  new  independ- 
ent tumours  resulting  from  neiv  injurious  agencies. 

The  diagnosis  of  carcinoma. is  in  general  not  difficult  if  what  has  been 
said  be  borne  in  mind.  A  differential  diagnosis  may  have  to  be  made  from 
tubercular  and  syphilitic  growths.  A  careful  microscopic  examination  of  an 
excised  j)ortion  of  the  tumour  will  usually  clear  up  any  uncertainty.  If 
syphilis  is  suspected,  antisyphilitic  treatment  should  be  begun  (iodide  of 
potassium,  mercury,  etc.),  and  when  the  latter  disease  is  present  such  a 
method  of  ti'eatment  will  be  successful,  but  not  in  cases  of  carcinoma. 

Treatment  of  Carcinoma. — The  treatment  of  carcinoma  consists  in  as 
early  an  extirpation  as  possible.  During  the  later  stages  an  attempt 
should  at  least  be  made  to  check  its  course  and  improve  the  general 
condition  of  the  patient.  In  extirpation  with  the  knife  as  much  of  the 
healthy  tissue  as  can  be  spared  should  be  included,  so  as  to  leave  no 
tumour  cells  behind.  The  adjacent  region  with  its  tissue  spaces  and 
lymphatics  is  more  or  less  filled  with  carcinoma  cells,  and  hence  the 
difficulty  in  advanced  cases  of  extirpating  the  entire  growth  in  toto. 
The  nearest  lymph  glands  should  hence  always  be  removed  ;  thus,  in 
every  amputation  of  the  breast,  for  example,  the  axilla  should  be 
opened  and  the  glands  and  all  the  fat  removed,  even  though  no  enlarge- 
ment of  the  former  can  be  felt  from  without.  After  the  axilla  has 
been  cut  into,  slightly  enlarged  lymph  glands  are  often  found  in  cases 
where  they  were  not  suspected.  Complete  cures  sometimes  result 
from  an  early,  careful  extirpation  of  a  carcinoma,  and  if  no  recurrence 
appears  within  one  and  a  half  to  two  years  the  patient  is  to  be  regarded 
-as  probably  entirely  freed  from  his  disease.  I  have,  however,  occasion- 
ally seen  recurrence  take  place  four  to  five  years  after  the  first  opera- 
tion. One  generally  occurs  sooner  or  later,  and  after  extirpation  of 
this,  the  carcinoma  very  frequently  reappears  in  a  still  shorter  time, 
making  it  seem  in  many  cases  as  though  recurrences  were  hastened 
and  increased  in  virulency  by  each  succeeding  operation. 

The  different  methods  of  operation  for  carcinoma  with  the  knife, 
galvano-cautery,  thermo-cantery,  etc.,  are  described  in  the  chapters  on 
g;eneral  surgical  technique,  and  the  extirpation  of  carcinomata  in  dif- 
ferent parts  of  the  body — the  skin,  breast,  mouth,  stomach,  intestine, 
uterus,  etc. — is  described  in  the  Regional  Surgery.  Xussbaum  has  rec- 
ommended for  suitable  cases  the  extirpation  of  carcinomata  by  means  of 


824  TUMOURS. 

the  thermo-cautery.  It  is  claimed  that  recurrences  are  not  so  common 
after  this  method  on  account  of  the  more  intense  reaction  of  the  wound 
and  the  firm  scar.  For  the  same  reason  Bougard  and  others  have  rec- 
ommended again  cauterisation  with  caustic  pastes  (chloride  of  zinc, 
caustic  points,  see  page  777).  Generally  speaking,  the  thorough  re- 
moval of  the  carcinoma  with  the  knife  is  the  most  effectual  method  of 
operation. 

The  treatment  of  inoperable  carcinomata  is  symptomatic.  Accord- 
ing to  the  nature  of  the  case,  a  trial  may  be  made  of  the  various  meth- 
ods already  mentioned  in  connection  with  the  treatment  of  tumours  in 
general.  These  include,  in  addition  to  a  general  strengthening  regi- 
men, parenchymatous  injections,  the  arsenic  treatment,  and  circum- 
cision with  the  thermo-cautery  in  order  to  diminish  the  growth,  pain, 
and  final  sloughing  of  the  carcinoma.  In  sloughing  cancers,  use  may 
be  made  of  the  sharp  spoon,  thermo-cautery,  and  dressings  filled  with 
deodorizing  sabstances,  such  as  acetate  of  aluminium,  carbolic  acid,  bi- 
chloride of  mercury,  iodoform,  and  naphthaline.  ISTarcotics  in  the  form 
of  subcutaneous  injections  of  morphine  are  often  indispensable.  The 
inoculation  of  erysipelas  has  already  been  spoken  of  on  page  778.  Czerny 
saw  two  cases  of  recurrent  carcinoma  cured  by  inoculation  of  erysipe- 
las ;  the  duration  of  the  cure  was  two  and  six  years  respectively.  For 
the  description  of  Emmerich's  curative  serum  and  Coley's  fluid,  see  pages 
354  and  778.  It  is  frequently  necessary  to  perform  an  operation  for 
the  treatment  of  the  sequelae  of  an  inoperable  carcinoma ;  a  tracheoto- 
my may  be  required,  for  example,  in  carcinomatous  stenoses  of  the 
larynx,  or  the  formation  of  an  artificial  anus  in  carcinoma  of  the  intes- 
tine. Whether  the  growth  of  the  disease  is  influenced  by  the  trans- 
plantation upon  it  of  healthy  skin  (Goldmann)  cannot  as  yet  be  defi- 
nitely decided. 

For  other  methods  of  treatment,  including  the  use  of  arsenic  and 
numerous  other  remedies,  see  page  778.  Further  methods  of  treat- 
ment are  as  follows :  Clay  (Birmingham)  speaks  well  of  the  local  and 
internal  action  of  turpentine  (in  the  form  of  the  essence  made  by 
Southall  and  Barclay  in  Birmingham,  two  teaspoonfuls  three  or  four 
times  a  day,  with  pills  of  sulphur  and  sulphate  of  copjjer,  etc.  ;  also 
local  injections  into  the  tumour).  Denissenko  reports  good  results  from 
the  use  of  extractum  chelidonii  (injections  are  made  into  the  carci- 
noma every  three  to  five  days  of  one  to  two  hypodermic  syringefuls 
containing  either  equal  parts  of  the  extract  and  glycerine  and  distilled 
water,  or  two  parts  of  the  extract  with  one  part  each  of  glyeei'ine  and 
water  ;  internally,  one  and  a  half  to  five  grammes  are  given,  or  the  ulcer- 
ations are  packed  or  coated  with  two  parts  of  the  extract  and  one  part 


130.] 


CYSTS— ATHEROMATA,  TERATOMATA. 


825 


glycerine).  Other  remedies  are :  Glycerine  alveolo  juice  (a  euphor- 
biaceae)  and  resorcin  locally ;  decoction  (Zittmann's)  internally,  cal- 
cium carbonate  and  condurango  bark  internally  and  locally — all  of 
which  are  probably  without  real  value.  Adamkiewicz  has  made  use 
of  a  substance  called  by  him  cancroin,  which  consists  of  the  poisonous 
products  of  cancer  tissue.  As  the  general  use  of  cancroin  is  attended 
with  practical  difficulties,  he  recommends  a  substance  with  a  similar 
action  called  neurin  (C2H3]Sr(CH3)OH),  which  is  used  in  the  form  of 
hypodermic  injections  in  doses  of  fifteen  centigrammes  to  one  gramme 
a  day.  Nothing  definite  can  be  said  at  present  about  the  real  thera- 
peutic importance  of  this  remedy,  but  I  doubt  its  value.  Snow,  at  the 
cancer  hospital  in  London,  recommends  the  opium  pipe  as  a  palliative 
measure  in  inoperable  carcinomata,  and  also  as  a  preventive  against  re- 
currences. Esmarch  and  others  have  recommended  for  cancer  jDatients 
a  diet  consisting  of  but  little  nitrogenous  material. 

§  130.  Cysts — Atheromata,  Teratomata,  Cyst-formation  in  Different 
Tumours. — The  formation  of  cysts  takes  place,  as  we  have  already  said, 
in  many  different  kinds  of  tumours  in  consequence  of  softening,  espe- 
cially in  adenoma  (cysto-adenoma),  fibroma 
(cysto-fibroma),  and  sarcoma  (cysto-sarco- 
ma).  The  proliferating  cystoma  of  the  ova- 
ries, kidneys,  or  mammse,  in  which  a  new 
production  of  cysts  takes  place,  belongs  to 
the  class  of  the  true  cystic  tumours.  But,  in 
the  main,  these  proliferating  cysts  are  ade- 
nomata ;  a  proliferation  of  cells  first  occurs, 
and,  secondarily,  the  formation  of  cysts  as 
a  result  of  mucoid  and  colloid  degeneration 
of  the  cells.  This  continues,  nntil  finally 
very  large  tumours  are  developed,  particu- 
larly in  the  ovaries.  Cystic  goitres  also 
begin  as  adenomata. 

Bone  cysts  are,  as  a  rule,  either  enchon- 
dromata,  fibromata,  or  sarcomata,  which  have 
undergone  cystic  degeneration  (Fig.  51-i),  or 
true  proliferating  cystic  tumours.  To  the 
latter  belongs  that  cystic  degeneration  which 

often  simultaneously  attacks  all  the  bones  of  the  body,  and  is  perhaps 
to  be  regarded  as  a  constitutional  disease.  Bramann  found  a  multiple 
formation  of  cysts  in  a  great  number  of  the  bones  of  a  woman  thirty- 
four  years  old,  who  had  osteomalacia.  Many  bone  cysts  are  probably 
due  to  infiammatory  processes  or  haemorrhages  (Schlange).     The  soli- 


FiG.  514. — Cysto-sarcoma   of  the 
femur  (Busch  i. 


826 


TUMOURS. 


Fig.  515. — Proliferatincr  follicular  dental  c\st 
of  the  lower  jaw  in  a  peasant  tliirty-two 
years  of  age  (Bryk). 


tar  J  evsts  of  the  long  bones  (Fig.  514)  occur  most  commonly  in  the 

femur.     They  develop  usually  in  the  medulla  at  the  ends  of  the  diaph- 

ysis ;  the  surrounding  tissue  usu- 
ally consists  of  tumour,  either  chon- 
droma, fibroma,  or  sarcoma,  so  that 
the  cysts  are  to  be  explained  as  a 
softening  process  within  the  tumour 
in  question.  Tlie  solitary  bone 
cysts  have  in  general  a  favourable 
prognosis ;  they  can  be  completely 
extirpated,  although  clinically  they 
bear  some  resemblance  to  sarcoma. 
Cysts  of  the  long  bones  lead  to 
curvatures  and  fractures  of  the 
same.  The  cysts  of  the  jaw  and 
teeth  (Fig.  515)  arise  either  from 
the  periosteum  or  from  the  dental 
follicles  as  a  result  of  disturbances 
of  development.  Here  also  the  pro- 
liferation of  cells  takes  place  first, 

and  then  a  progressive  formation  of  cysts  follows.     A  large  number  of 

cysts,  originating  in  a  great  variety  of  ways,  are  congenital ;  these  have 

been  described  very  fully  by  Lannelongue 

and  Archard.    Other  cysts  are  due  to  para- 
sites, such  as  Echinococcus  and  Cysticercus 

celluloscB,  and  are  found  in  various  organs 

of  the  body. 

The  contents  of  the  cysts  are  serous, 

mucous,  or  bloody.     A  distinction  is  made 

between  simple  and  compound  or  multi- 

locular  cysts.     The  interior  of  the  latter  is 

divided  off  by  septa,  and,  in  some  instances, 

new  cysts  form  in  the  walls  of  the  old  ones. 
The  retention  cysts  do  not  belong  to  the 

true  tumours,  as  in  these  cases  an  abnormal 

new  growth  of  cells  does  not  occur,  but 

only  an  accumulation  of  secretion.     With 

Yirchow,  we  divide  the  retention  cysts  into 

(1)  mucous  cysts,  (2)  follicular  cysts,  and 

(3)  retention    cysts  starting  in  the  excre- 
tory duct  or  the  acini  of  large  glands.     Mucous  cysts,  which  result 

from  the  retention  of  the  secretion  of  the  mucous  glands,  are  found 


Fig.  516. — Woman,  fifty-nine  years 
of  age  with  sebaceous  cysts  of 
the  scalp  ;  a  typical  epithelioma 
developed  in  one  cyst  which 
suppurated. 


§  130.]  CYSTS— ATHEROMATA,  TERATOMATA.  827 

especially  in  the  mucous  membrane  of  the  lips,  the  cheeks,  the  antrum 
Highmori,  the  respiratory  and  digestive  tract,  the  vagina,  the  uterus, 
etc.  The  follicular  cysts  include  the  comedones,  those  well-known 
little  spots  in  the  skin,  often  of  a  black  colour,  which  are  plugs  or 
secretions  in  the  hair  follicles,  and  the  miliuTn  resulting  from  a  similar 
accumulation  of  secretion  in  the  sebaceous  glands.  The  atheromata  or 
sebaceous  cysts  are  retention  cysts  of  the  hair  follicles.  The  latter 
continue  to  form  their  secretion,  and  consequently  the  sac  becomes 
more  and  more  tense ;  and  thus  are  developed  in  the  skin  the  well- 
known  tumours  which  vary  in  size  from  that  of  a  small  pea  to  that 
of  a  fist  or  a  child's  head,  and  contain  epidermis,  fat,  and  crystals  of 
cholesterin.  A  second  variety  of  atheroma  is  situated  not  in  the  skin, 
but  deeper  down  in  the  subcutaneous  tissue.  These  deep  subcutaneous 
atheromata  are  probably  the  result  of  separated  embryonic  remnants 
of  skin  tissue  which  contain  sebaceous  glands  or  groups  of  epithelium 
belonging  to  the  epidermis.  In  the  latter  case  they  might  be  called 
epidermoids  (Franke).  Franke  thinks  that  atheromata  are  not  reten- 
tion cysts  of  the  skin  follicles,  but  represent  true  new  growths  which 
have  sprung  from  embryonic  cells.  The  atheromata  sometimes  grad- 
ually break  through  the  integument,  and  become  complicated  by 
inflammation,  suppuration,  or  even  epithelioma  (Fig.  516).  Hence 
extirpation  of  atheromata  is  always  indicated.  Cutaneous  horns  occa- 
sionally develop  from  open  atheromata  with  fistulas. 

Among  the  retention  cysts  which  arise  from  the  excretory  ducts  or 
acini  of  large  glands  may  be  mentioned  the  retention  cysts  of  the  liver, 
the  mamma,  and  the  kidney ;  also  the  so-called  ranula  under  the  tongue 
near  the  frenum  resulting  from  the  closure  of  the  excretory  ducts  of 
the  submaxillary  and  sublingual  glands,  and  particularly  of  the  Blandin- 
iN'uhn  glands — two  mucous  glands  situated  near  the  tip  of  the  tongue. 

Cysts  are,  moreover,  found  in  structures  which  do  not  persist  after 
the  birth  of  the  foetus ;  examples  of  these  are  branchiogenic  cysts  of 
the  neck,  cysts  of  the  urachus,  etc. 

We  have  already  mentioned  the  occurrence  of  blood  and  lymph 
cysts  due  to  a  gradual  dilatation  of  blood-  and  lymph-vessels. 

By  cliolesteatoma  is  meant  either  an  atheroma  or  a  dermoid  cyst,  with 
characteristic,  often  silky  white  contents  which  are  made  up  of  fat,  choles- 
terin, and  groups  of  cells  which  shine  like  mother-of-pearl.  The  cholestea- 
tomata  are  found  especially  in  the  brain  and  its  meninges  ;  also  in  the  ovaries, 
in  the  subcutaneous  cellular  tissue,  and  in  bone  (petrous  portion  of  the  tem- 
poral). According  to  Eppinger  and  others,  the  cholesteatomata  are  essen- 
tially endotheliomata  (see  page  803).  Glaeser  examined  one  which  was  found 
on  the  base  of  the  brain,  and  came  to  the  conclusion  that  the  cells  of  the 
cholesteatoma  develop  from  the  endothelia  of  the  lymph  spaces  of  the  arach- 


828  TUMOURS. 

noid  by  growth  and  concentric  division.  Kulin  is  disposed  to  think  that  tlie 
cholesteatomata  of  the  ear  are  principally  congenital  in  origin.  Politzer 
found  small  roundish  bodies  in  the  mucous  membrane  of  the  ear  which 
increase  in  size  and  lead  to  the  formation  of  these  tumours.  The  suppuration 
and  sloughing  which  accompany  cholesteatomata  of  the  ear  are  secondary 
conditions,  and  not,  as  Habermann  thinks,  the  cause  of  their  development. 
These  sequela?  lead  not  infrequently,  in  cholesteatomata  of  the  ear  to  death 
of  the  patient ;  and  hence  Kuhn  emphasises  the  necessity  of  a  radical  removal 
by  osteotomy,  if  it  is  required,  of  the  portion  of  the  bone  in  question  (mastoid 
process).  The  etiology  of  cholesteatomata  of  the  middle  ear  and  the  meatus 
is  probably  complex  ;  some  of  the  cases  are  certainly  endotheliomata,  while 
others  are  the  result  of  a  simple  proliferation  of  epithelial  cells,  or  a  change 
of  epithelial  cells  into  epidermis.  The  etiology  of  cholesteatomata  has  an 
extremely  interesting  bearing  upon  the  etiology  of  tumours  in  general,  show- 
ing, as  it  does,  that  tumours  can  arise  from  the  cells  of  the  mesoderm  which 
correspond  exactly  to  those  that  originate  from  epithelium. 

The  treatment  of  cysts  depends  largely  upon  their  location  and  their 
cause ;  it  consists  in  extirpation,  aspiration,  incision,  parenchymatous 
injection  of  various  fluids,  such  as  absolute  alcohol  with  or  without 
tincture  of  iodine,  etc.  (see  page  TT6,  Treatment  of  Tumours  in  Gen- 
eral). The  treatment  of  cysts  of  the  different  parts  of  the  body  is 
described  in  the  Regional  Surgery.  Sebaceous  cysts  are  either  extir- 
pated with  the  overlying  skin,  or  an  incision  is  made  over  the  tumour, 
the  latter  separated  on  all  sides  with  a  probe  or  narrow  flat  instrument 
from  the  surrounding  tissue  and  then  removed  i7i  toto  without  opening 
the  sac.  One  should  be  sure  to  remove  the  entire  cyst  wall.  Another 
method  is  to  make  a  small  incision  at  the  base  of  the  cyst,  separate  the 
latter  from  its  surroundings  by  a  probe,  and  then  lengthen  the  incision 
sufficiently  to  remove  the  tumour.  The  easiest  way  usuaDy  is  to  divide 
the  cyst  wall  by  the  skin  incision  and  extract  the  two  halves  with  a 
forceps. 

Teratomata  are  congenital  tumours  or  malformations  which  are 
made  up  of  a  great  variety  of  tissues.  They  include  both  the  double 
monstrosities,  in  which  one  embryo  is  rudimentary  and  united  to  the 
other,  and  malformations  which  have  taken  place  in  a  single  foetus. 
All  sorts  of  structures  have  been  found  in  congenital  tumours  and 
cysts.  Kiimmel  discovered  in  a  congenital  coccygeal  neoplasm  a  body 
that  resembled  an  eye,  which  was  similar  to  one  found  by  Marchand 
and  Baumgarten  in  an  ovarian  cyst.  Kockel  has  recently  made  an 
exhaustive  study  of  teratomata  of  the  testicle  ;  he  believes  that  they  are 
not  the  result  of  the  inclusion  of  fcetal  elements  but  of  a  partial  unilat- 
eral hermaphroditism ;  the  ovarian  portion  of  the  testicle  is  the  point 
of  origin  of  the  tumour.  A  large  number  of  the  so-called  complex 
cystic  tumours  of  the  testicle  probably  belong  to  the  teratomata.     The 


§  130.]  CYSTS— ATHEROMATA,  TERATOMATA.  829 

embryonic  cjstomata  of  the  testicle  are,  according  to  Kockel,  entirely 
analogous  with  those  of  the  ovary,  and  represent  rudimentary  para- 
sitic foetuses.  (For  further  particulars  concerning  teratomata  of  the 
testicle  and  ovary,  see  Regional  Surgery.) 

The  dermoid  cysts  also  belong  in  this  class ;  they  have  an  inner 
wall  which  is  analogous  to  the  skin,  and  may  occur  in  organs  where 
skin  is  not  normally  present.  They  are  most  commonly  found  in  the 
ovary,  and  also  in  the  peritonaeum,  neck,  orbits,  nose,  and  in  the  sacral 
and  coccygeal  regions.  The  wall  of  the  cyst  consists,  as  we  have  said, 
of  epidermis  and  corium,  with  sebaceous  glands,  hair  follicles,  and  less 
often  sweat  glands.  The  contents  usually  consist  of  a  fatty,  yellow- 
ish or  whitish,  greasy  mass,  together  with  hairs,  cartilage,  bone,  and 
even  teeth.  In  very  rare  cases,  brain,  nerve,  and  muscle  tissue  or 
structures  resembling  extremities  have  been  found.  Occasionally  the 
contents  are  oily  (oil  cysts).  Kocher  and  Streit  have  laid  emphasis 
upon  a  peculiarity  possessed  by  these  tumours — when  not  filled  too 
full — of  retaining  for  a  considerable  length  of  time  any  change  of 
form  which  is  given  them.  This  is  due  to  their  homogeneous  cement- 
like contents.  If  epithelial  cells  and  masses  of  fat  are  mixed  with  a 
large  amount  of  hair,  a  peculiar  crepitation  may  be  felt  on  palpation 
of  the  tumour  (Kocher).  The  dermoid  tumours  develop  from  stray 
cutaneous  cells  which  have  been  inverted,  as  in  the  closure  of  embry- 
onic clefts.  At  the  same  time  cells  of  the  entoderm  may  become  dis- 
placed or  separated. 

Implantation  Cysts. — Cysts  sometimes  occur  on  the  fing-ers  and  toes, 
and  more  rarely  in  other  parts — e.  g.,  between  the  cranial  bones  and  the 
dura  as  the  result  of  traumatisms.  They  are  caused  by  the  proliferation  of 
epithelial  cells  which  have  becorae  displaced  by  traumatism  (Eeverdin,  Kauff- 
mann,  Garre,  etc.).  There  is  a  connective-tissue  sac  which  contains  epithelial 
pearls,  or,  in  the  case  of  large  tumours,  a  gi'umous  or  pulpy  material  similar  to 
that  contained  in  sebaceous  cysts.  Giant  cells  are  found  particularly  in  the 
presence  of  foreig-n  bodies  (Bohm).  These  cysts  can  also  result  from  the 
proliferation  of  displaced  groups  of  foetal  cells,  as,  for  example,  in  the  forma- 
tion of  the  interdigital  furrows  (Labouyle). 

Polypous  appendages  are  sometimes  found  upon  different  parts  of 
the  surface  of  the  body.  They  are  to  be  looked  upon  as  abnoi'mal  dis- 
placements of  tissue  or  malformations  depending  upon  an  imperfect 
closure  of  embryonic  clefts.  Such  tumours  or  cutaneous  appendages, 
occasionally  containing  cartilage,  are  found  in  the  vicinity  of  the  lines 
of  closure  of  the  dorsal  or  ventral  clefts,  or  near  the  face,  ears,  neck, 
anal  region,  or  the  rhaphe  of  the  perinseum  (Chiari). 


INDEX 


Acetabulum,  wandering  of  the,  701,  703. 
Acetal  as  anfesthetic,  47. 
Acetate  of  aluminium,  163. 
Aceto-tartrate  of  aluminium,  163. 
Acne,  530. 
Acromegaly,  676. 
Acromicria,  677. 
Actinomyces,  45.5. 
Actinomycosis,  455. 

diagnosis  and  pfognosis  of,  460. 

occurrence  in  animals,  457. 

occurrence  in  man,  458. 

treatment  of,  461. 
Aeufilopressure,  101. 
Acupressure,  101. 
Adenoid,  810. 
Adenoma,  810. 
Air  cushions,  305. 

Air,  entrance  of,  into  veins,  65,  467. 
Alcohol  dressings,  170. 
Alumnol,  173. 
Amcebse.  383. 

Amputation,  general  technique  of,  and  indi- 
cations for,  119,491. 

after-treatment  of,  139. 

artificial  limbs  after,  13.3. 

bad  results  after,  180. 

mortality  of,  133. 

subperiosteal,  139. 
Amputation  in  cases  of  fracture,  636. 
Amputation  knives,  131. 
Amputation  neuroma.  131. 
Amputation  stump,  conical,  131. 
Amputation  with  scraping  out  the  medulla, 

641. 
Aneemia,  artificial,  54.     (See  also  Ischae- 

mia.) 
Anfesthesia,  17. 

local,  49. 
Antesthetics,  17-53. 
Anatomical  tubercle,  387. 
Anchylosis,  696-734. 
Aneurisms,  553. 

diagnosis  and  prognosis  of,  557. 

symptoms  of.  .556. 

treatment  of,  558. 

varieties  of,  553-556. 
Angeioraa,  789. 
Angeio-keratoma,  808. 


Angeio-sarcoma,  791. 
Angiotripsy,  97. 
Aniline  dves  as  antiseptic,  173. 
Anthrax,  "388. 

attenuation  of  virulence   of  bacilli  of, 
391. 

bacillus  of,  389. 

etiology  of,  389. 

immunity  from,  393. 

in  animals,  393. 

in  man,  393. 

occurrence  and  origin  of,  391. 

stain  of  bacilli  of,  393. 
Antisepsis,  3. 
Antiseptic  dressings,  153. 
Antiseptics,  157. 
Aorta,  congenital  stenosis  of,  553. 

ligation  of,  300. 
Aphthje  epizooticje,  403. 
Apparatus  for  permanent  irrigation,  181.. 
Argentura  nitricum,  85. 
Aristol,  169. 
Arm,  bandages  for,  193. 
Arrow  poison  of  Indians,  413, 
Arsenic  paste,  85. 
Arteries,  551. 

aneurisms  of,  553. 

digital  compression  of,  53. 

diseases  of,  551. 

hfemorrhage  from,  93,  463. 

inflammation  of,  335. 

ligation  of,  93,  101. 

punctured  wounds  of,  470. 

suture  of,  98. 

Umstechung,  97. 
Arteritis.  335. 
Artery  clamps,  93. 
Arthrectomy,  135. 
Arthritis,  acute,  684. 

chronic,  694. 

deformans,  710. 

syphilitic,  708. 

tubercular,  699. 

urica,  689.     (See  also  Joints.) 
Arthrodesis,  139. 
Arthrolysis,  139. 
Arthropathia  tabidorum,  730. 
Arthrospores,  365. 
Arthrotomy,  135. 

831 


832 


INDEX. 


Articular  rheumatism,  687. 

acute  polyarticular.  687. 

chronic,  G'JG. 
Aseptin,  168. 
Aspergillus.  257. 
Asphyxia.  29. 
Aspiration.  75. 
Aspirators.  75.  76. 
Atheroma.  827. 

Atrophy  of  skin,  idiopathic,  543. 
Auscultation  of  bone,  616. 
Auto-transfusion,  57,  493. 

Bacilli,  261.     (See  also  the  separate  infec- 
tious diseases.) 
Bacillus  of  anthrax.  389. 

coli  communis.  341. 

of  diphtheria,  547. 

of  Ernst.  331. 

of  glanders.  397. 

of  leprosy.  450. 

of  malignant  oedema,  339. 

of  mouse  septicfemia,  372. 

pyocyaneus.  331. 

of  rabbit  septicemia,  372. 

of  symptomatic  anthrax,  396. 
Bacteria,  action  of  pathogenic.  273. 

attenuation  of  virulence  of,  275. 

conditions  suited  to  life  of,  265. 

culture  media  for,  272. 

of  decomposition,  373. 

experimental  transmission  of,  280. 

formation  of  pigment  by,  269. 

immunity  from  effects  of,  277. 

infectious.  327. 

influence   of  constant  electric  current, 
upon.  267. 

influence  of  light  upon,  267. 

influence  of  oxygen  upon,  266. 

influence  of  temperature  upon.  266. 

intra-uterine  transmission  of.  280. 

linear  cultures  of.  273. 

methods  of  studying,  271. 

movements  of.  262. 

needle-point  cultivation  of,  273. 

non-pathogenic,  281. 

pathogenic,  281. 

phosphorescence  of,  269. 

power    of    organism    to   protect    itself 
against.  276. 

piroducts  of  metabolism  of.  267,  269. 

restraint  upon  growth  of.  270. 

structure  and  reproduction  of.  262. 

toxic,  274. 
Bacterial  proteins,  236,  242. 
Bandages,  application  of,  188. 

handkerchief.  197. 

for  the  head.  190. 

for  the  lower  extremity,  195. 

for  the  mamma.  192. 

for  the  neck  and  thorax,  192. 

for  the  shoulder.  195. 

for  the  upper  extremity,  193. 
Barracks  in  war.  765. 

Docker's,  765. 


Baths,  permanent,  after  injuries,  183. 

Batteries,  electric,  82. 

Beds,  movable,  203. 

Bee  stings.  410. 

Benzoic  acid,  170. 

Bichloride  of  mercury,  159. 

poisoning  bv.  161. 

stability  of,"  160. 
Bichloride  gauze,  preparation  of,  160. 
Binoculus,  192. 
Birth-mark.  790. 
Bismuth,  163. 
Bistoury,  69. 
Blastomycetes.  259. 
Blood,  coagulation  of,  297. 

regeneration  of,  467. 

treatment  of  loss  of,  493. 
Blood-corpuscles,  white,  emigration  of,  235. 

reaction  of.  to  staining  reagents.  299. 
Blood  cysts.   791.      (See  also   Angeioma, 

Lymphangeioma,  and  Cysts.) 
Bloodless  operation,  1. 
Blood  transfusion,  494,  496. 
Blood-vessels,  551. 

aneurisms  of.  552. 

diseases  of.  551.  • 

injuries  of.  463. 

ligation  of.  93. 

punctured  wounds  of,  470. 

suture  of.  98. 

torsion  of,  97. 

Umstechnng.  97. 

varices,  560. 
Boiler  for  sterilisation  of  instruments,  4. 
Bone,  abnormal  fragility  of,  593. 

ab.scess  of,  654. 

absorbable  drains  of,  108. 

absorption  of.  605. 

acromegaly.  676. 

acromicria,  677. 

acute  inflammation  of.  633. 

acute  osteomyelitis.  634. 

atrophy  and  hypertrophy  of,  672. 

caries  of.  646.  653. 

cavities,  treatment  of,  608. 

chronic  inflammations  of,  643. 

contusions  of.  631. 

cysticercus  cellulosje,  678. 

division  of.  86. 

echinococcus  of.  678. 

formation  of,  603. 

giant  growth.  675. 

gunshot  injuries  of.  757. 

implantation  of.  150. 

increased  growth  of.  604,  675. 

inflammations  and  diseases  of,  633. 

inflammation  of  marrow  of,  634. 

injuries  and  fi'acture  of,  589. 

metastatic  inflammations  of,  641. 

necrosis  of.  655. 

neuralgia  of.  720. 

neuropathies  of,  720. 
in  svringomyelia,  722. 
tabetic,  720.' 

operations  upon,  86. 


INDEX. 


833 


Bone,  osteomalacia,  669. 

percussion  and  auscultation  of,  616. 

plastic  surgery  upon,  150. 

resection  of,  in  continuity,  135. 

rhachitis,  663. 

sawing  of,  86. 

strength  of.  591. 

suture  of,  117. 

syphilis  of,  652. 

transplantation  of,  629. 

tuberculosis  of,  645. 

tumours  of,  678. 

uniting,  by  nails,  117. 

wounds  of,  631. 
Bone  forceps,  87, 
Bone  screws,  118. 
Bone  shears,  87. 
Borated  lint,  163. 
Boras,  162. 
Boric  acid,  162. 
Boric-acid  ointment,  163. 
Boro-glycerine  lanolin,  163. 
Boro-salicylic  solution,  160. 
Box  splint,  Heister's,  205. 
Branchiogenic  cysts,  827. 
Bromethyl.  47. 
Bromethylene,  48. 
Bromoform,  48. 
Bullets,  discovery  by  magnet  of,  766. 

extraction  of,  768. 

healing  in  of,  762. 
Burns,  499. 

causes  of  death  from,  502. 

from  lightning,  506. 

prognosis  of.  503. 

symptoms  of,  499. 

treatment  of,  504. 
BursiB,  diseases  of,  580. 

Cadaver  alkaloids,  infection  by,  386. 
Cadaver  infection,  treatment  of,  387. 
Cadaver  tuberculosis,  387. 
Callus,  formation  of,  602. 

delayed  formation  of,  614. 

treatment  of  delayed  formation  of,  628. 
Callus  luxurians.  607. 
Cancer  (see  Carcinoma),  811. 
Canquoin's  paste,  85. 
Capistrum  duplex,  191. 
Capitium  parvum,  198. 

magnum,  199. 

quadrangulare,  199. 
Caput  obstipum  (congenital),  524. 
Carbolic  acid,  157. 

detection  of,  in  urine,  159. 

poisoning  by,  158. 
Carbolised  gauze,  158. 
Carbolised  glycerine,  158. 
Carbonic  acid  as  an  anaesthetic,  48. 
Carbuncle,  531. 
Carcinoma,  811. 

curabilitv  of,  822. 

etiology  of.  816. 

histology  of.  815. 

micro-organisms  of,  819. 
56 


Carcinoma,  transmission  of,  820. 

treatment  of,  823. 
Caries  of  bone,  646,  653. 
Cartilage,  fibrillation  of,  710. 

fractures  of,  597,  610. 

histologv  of,  683. 

inflammation  of,  696,  700,  710. 

injuries  of,  597,  610. 

repair  of  fractures  of,  610. 

repair  of  wounds  of.  754. 
Cataplasm,  183. 
Catgut,  capillary  drain  of,  108. 

ligatures  of,  94. 

preparation  of,  94. 

sterilisation  of.  14,  95. 

sutures  of,  112. 
Caustic  pastes,  85. 
Caustics,  different  kinds  of,  85. 

use  of,  85. 
Cavernoma.  790. 
Cellulitis,  338. 

prognosis  of.  344. 

symptoms  of.  341. 

treatment  of.  344. 
Cellulose  splints.  215. 
Cement  dressing,  226. 
Chain  saw,  89. 
Chemotasis,  236. 
Chin  bandage,  191. 
Chisels,  87. 
Chloride  of  zinc,  162. 
Chloride-of-zinc  paste,  85. 
Chloroform,  19. 

accidents  during  narcosis  of,  29. 

apparatus  for  administering,  24. 

chemical  composition  of,  19. 

death  from,  30. 

decomposition  of,  by  gas  fiame,  27. 

narcosis  of,  19. 

physiological  action  of,  19. 

statistics  of  death  from,  31. 

symptomatology  of  narcosis  of,  27. 

treatment  of  accidents  during  narcosis 
of,  36. 
Chloroform-morphine  narcosis,  46. 
Chloroform-oxvgen  narcosis.  85. 
Chloroma,  806." 
Cholesteatoma,  827. 
Chondroma,  785. 
Choudrostitis  dissecans,  662. 

luetiea,  653. 
Cicatrix,  formation  of.  251. 

malignant  neoplasms  of,  305. 

paralysis  from.  305. 

subsequent  changes  in.  305. 

tumours  of,  305,  781. 

ulcers  of.  305. 
Clavi,  808. 
Clastridium.  262. 
Club-foot.  727. 
Coagulation  necrosis,  546. 
Cocaine  (as  anfesthetic).  49. 
Cocci,  various  kinds  of,  261. 
Coceidia.  282. 
Cold,  effects  of,  509. 


834 


INDEX. 


Colli,  use  of,  185. 
Cold  abscess,  647.  701. 
Collateral  circulation  after  ligation  of  ar- 
teries, 302. 
Collodion,  dressings  of,  186. 
Comedones,  827. 
Compresses,  split.  123. 
Compression  (as  method  of  hfemostasis), 

99. 
Condyloma  acuminatum,  809. 
Condyloma  latum,  440. 
Congestion  abscess,  647,  701. 
Conidia,  256. 

Connective  tissue,  growth  of,  289. 
Continuous  suture,  114. 
Contractures,  cicatricial,  305,  500,  734. 

inflammatory,  569. 

ischa?mic,  569. 

of  joints,  726. 

myopathic,  734. 

neuropathic,  729. 

pai-alytic,  730. 

spastic,  729. 
Contusions,  513. 

symptoms  of,  514. 

treatment  of,  520. 
Contusions  of  bones,  631. 
Contusions  of  joints,  736. 
Corpora  oryzoidea,  581. 
Corsets,  224. 

Cotton-starch  dressing,  223. 
Creolin,  171. 

Croton  oil  as  an  irritant,  237. 
Croup,  545. 
Crutch-paralysis,  135. 
Curare,  413. 

Cushions  for  sick-bed,  205. 
Cutaneous  horns,  808. 
Cylindroma,  803. 
Cystoma,  825. 
Cysto-sarcoma,  825. 
Cysts,  825. 

Decomposition,  267. 

Decubitus,  584. 

Deformities  (contractures)  of  joints,  726. 

Delirium  nervosum,  323. 

Delirium  of  collapse,  323. 

Delii'ium  tremens,  321. 

treatment  of.  322. 
Dermatitis,  527. 
Dermatol,  169. 
Dermatolysis,  544. 
Dermoid  cysts,  829. 
Devouring  cells,  276. 
Dextrine  dressing,  225. 
Digital  compression  of  arteries,  54. 
Diphtheria,  bacilli  of,  547. 

etiology  of,  547. 
Diplococci,  261. 
Director,  71. 
Disarticulations.  128. 

after-treatment  of,  129. 

artificial  limbs  for,  133. 

mortalitv  of,  132. 


Disarticulations,  performance  of,  128. 

subperiosteal,  129. 
Disinfection  of  catgut,  94. 

of  the  dressings,  14. 

of  the  field  of  operation,  8. 

of  the  instruments,  12. 

of  the  operator  and  his  assistants,  10. 

of  silk,  14. 

of  sponges,  14. 
Dislocations  of  joints,  739. 

complicated,  744. 

congenital,  750. 

of  deformity,  750. 

of  destruction,  749. 

from  distention,  749. 

habitual,  745. 

inflammatory  (pathological).  749. 

of  the  interarticular  cartilages,  749. 

intra-acetabulai',  701. 

irreducible,  748. 

of  muscles,  525. 

of  nerves,  526. 

old,  748. 

of  tendons,  525. 

voluntary,  741. 
Distortion  of  joints,  737. 
Division  of  the  soft  parts,  69. 
Drainage,  105. 
Drainage  forceps,  106. 
Drains,  106. 

of  rubber  tubing,  107. 
Dressings,  antiseptic  and  aseptic,  152. 

change  of,  175. 

impromptu  or  temporary,  216. 
Dressing  forceps,  72. 
Dynamite  injuries,  286. 

Eburnatio  ossis,  647. 
Ecchondroses,  785. 
Ecchymoses,  514. 
Echinococcus,  678. 

of  bone,  678. 

in  the  joints,  680. 
Ecrasement,  78. 
Ecraseur,  78. 
Eczema,  528. 

following  use  of  antiseptics,  528. 

solare,  528. 
Electric  batteries,  82. 
Electrolysis,  83. 
Electro-motor,  90. 
Electro-puncture  of  the  heart,  38. 
Elephantiasis,  540. 
Elevators,  86. 
Emboli,  fat,  613. 
Emphysema,  gangrenous  or  septic,  341. 

traumatic,  474. 
Enchondroma,  784. 
Endarteritis,  551. 
Endothelioma.  803. 
Epiphyses,  spontaneous  separations  of,  662» 

strength  of,  594. 

syphilitic  separations  of,  653. 

traumatic  separations  of,  597. 
Epithelial  tumours,  807. 


INDEX. 


835 


Epithelioma,  815. 
Epithelioma  moUuscum,  809. 
Ergotine  gangrene,  584 
Ergotism,  584. 
Erysipelas,  346. 

cocci  of,  347. 

complications  of,  352. 

curative,  353. 

diagnosis  of,  354. 

habitual,  351. 

of  mucous  membranes,  348. 

prognosis  of,  355. 

symptoms  of,  348. 

treatment  of,  355. 

zoonotic,  357. 
Erythema,  527. 

migrans,  357. 

solare,  528. 

various  kinds  of,  527,  529. 
Esmarch's  artificial  ischaemia,  53. 

rubber  bandage,  55. 

rubber  tourniquet,  55. 
Ether,  39. 

Ethyl  chloride  as  local  anaesthetic,  48. 
Eucaine,  52. 
Eucalyptus,  171. 
Euphorin,  169. 
Europhen,  169. 
Exercise  bones,  571. 
Exostosis,  787. 
Exostosis  bursata,  718,  788. 
Extension  by  a  weight,  226. 
Extension  dressings,  technique  of  apply- 
ing, 226. 

modifications  of,  226. 
Extension  splints,  215. 
Extravasation  of  blood,  514. 

absorption  of,  518. 

changes  in,  518. 

of  lymph,  514. 
Extremity,  upper,  dressings  for,  193. 

lower,  dressings  foi',  195. 
Exudate,  various  kinds  of,  244. 

Farcy  (see  Glanders),  397. 
Fascia  lata,  shrinkage  of,  734. 
Fascia  nodosa,  191. 
Fat  emboli,  613. 
Favus,  258. 
Pelt,  plastic,  214. 
Fermentation,  259. 
Ferment  intoxication,  373. 
Fever,  305. 

body  weight  in,  311. 

condition  of  respiration  in,  310. 

condition  of  vessels  during,  310. 

definition  of,  317. 

digestion  during,  311. 

disturbances  of  nervous  system  in,  311. 

etiology  of,  312. 

explanation  of,  315. 

loss  of  heat  during,  316. 

muscular  system  in,  311. 

pathological  changes  in,  312. 

prognosis  of,  312. 


Fever^  pulse  in,  310. 

symptoms  of,  306. 

treatment  of,  317. 
Fever  in  subcutaneous  injuries,  516. 
Fibroma,  779. 

molluscum,  780. 
Field  hospitals,  765. 

improvisation  of,  765. 
Filopressure,  101. 
Finger  bandages,  193. 
Fistula,  536. 
Flexion,  forced,  as  a  method  of  checking 

haemorrhage,  99. 
Foot,  dressings  for,  194. 
Foot-  and  mouth-disease,  402. 

occurrence  of,  402. 

treatment  of,  403. 
Forceps,  toothed,  72. 
Foreign  bodies,  healing  in  of,  252. 

behaviour  in  the  wound,  475. 
Formation  of  new  tissue,  288. 

of  a  cicatrix  in  a  vessel,  296. 

of  fibrillar  connective  tissue,  289. 

of  new  vessels,  293. 
Fractures,  589. 

causes  of,  589. 

condition  of  urine  in,  602. 

diagnosis  of,  616. 

direct  fixation  of  fragments  by  nails,  su- 
tures, etc.,  621. 

disturbances  during  healing  of,  612. 

gunshot,  757. 

prognosis  of,  616. 

repair  of,  602. 

symptomatology  of,  598. 

treatment  of,  617. 

treatment  of  malunited,  630. 

various  kinds  of,  594. 
Fractures  involving  joints,  621,  624,  744. 
Freezing,  509. 
Frost-bite,  509. 

blebs,  510. 
Funda  maxillae,  197. 
Fungi,  255. 

pathological  importance  of,  257. 
Furuncle,  530. 

Galvano-cautery,  80. 

instruments.  81. 
Galvano-puncture,  83. 
Ganglion,  582. 

periostale,  643. 
Gangrjena  senilis,  584. 
Gangrene  foudi'oyante,  339. 
Gangrene  of  the  soft  parts,  583. 

of  bone,  655. 
Genu  valgum,  728. 

varum  rhachiticum,  665. 
Germicides,  tests  and  comparisons  of,  271. 
Glanders,  397. 

bacilli  of,  398. 

diagnosis  of,  401. 

in  animals,  399. 

in  man,  400. 

treatment  of,  401. 


836 


INDEX. 


Glass  splints,  224.  ♦ 

Glass  wool,  157. 

Glioma,  798. 

Glisson's  sling  for  extension,  231. 

Glue  dressing,  225. 

Gonococcus.  444. 

Gonorrhoea.  444. 

GonorrhQ?al  rheumatism,  688. 

Gout,  689. 

Gout  of  lead  poisoning,  690. 

Granulations,  formation  of,  290. 

anomalies  of,  539. 
Gum  and  chalk  dressing,  226. 
Gumraata,  440. 
Gummi  laec*.  186. 
Gutta-percha  splints,  214. 
Gymnastics,  216. 
Gypsum  dressing,  217. 

knife  for,  223. 

scissors  for,  223. 

various  metliods  of  applying,  218. 
Gypsum  splints,  219. 

HiTraarthros.  736. 
Hematoma,  514. 

absorption  of.  518. 

changes  in,  519. 
Hemophilia.  62. 

joint  diseases  complicating,  713. 
Hfemorrhage.  arrest  of,  92. 

arterial,  463. 

capillary,  464. 

causes  of  death  from,  466. 

death  from.  466. 

effects  of.  465. 

prevention  of.  during  operations,  53. 

regeneration  of  blood  after,  467. 

secondary.  492. 

treatment  of.  493. 

venous,  464. 
Haemostasis.  92. 

temporary.  479. 
Hairy  people,  790. 
Hammer,  surgical.  87. 
Hand,  bandages  for,  194. 
Hand  spra}',  15. 
Healing  beneath  a  scab,  180. 

microscopic  phenomena  in  the  healing 
of  a  wound,  288. 

per  primam  intentionem,  286. 

per  secundam  intentionem,  287. 
Hip.  bandages  for,  197. 
Histocym,  313. 
Hollow  needles.  75. 
Hospital  gangrene.  358. 

clinical  course  of,  359. 

etiology  of.  359. 

prognosis  of.  360. 

treatment  of.  360. 
Hydarthros.  acute,  684. 

chronic,  694. 
Hydrophobia.  403. 

action  of  poison  of,  405. 

attenuation  of  the  poison  of,  405. 

diagnosis  of,  408. 


Hydrophobia,  etiology  of,  403. 

experiments  upon,  404. 

in  dogs,  405. 

in  man,  406. 

prognosis  of,  408. 

protective  inoculation  with,  409. 

results  of  autopsy  in,  408. 

treatment  of,  408. 
Hygroma  of  bursae,  581. 

of  tendon  sheaths,  579. 
Hyperostosis,  644. 
Hypertrichosis  circumscripta,  790. 

universalis,  790. 
Hypodermic  needle.  76. 
Hysteria  after  injuries,  285,  546. 
Hysterical  joint  diseases,  718. 

Ice,  use  of,  185, 

Ice  bags.  185. 

Ichthyol.  172. 

Ichthyosis.  544. 

Immersion,  181. 

Immunity,  natural  and  artificial,  277. 

Impromptu  dressings,  197. 

Indian  arrow  poison,  413. 

Infantile  spinal  paralysis.  731. 

Infection  from  cadaver  alkaloids,  886. 

intra-uterine,  424,  437. 
Infectious  wound  diseases,  323. 

origin  of.  by  microbes.  323. 

various  kinds  of,  326-414. 
Inflammation,  233. 

causes  of,  238. 

croupous  and  diphtheritic.  246. 

diagnosis  and  treatment  of,  252. 

of  joints.  684. 

acute,  684. 

chronic.  694. 

movements  of  Ivmph  in.  236. 

nature  of,  239.  ' 

symptomatology  of.  243. 
Inflammation  and  suppuration  of  wounds 

326. 
Infusion  of  salt  solution,  494. 

indications  for.  496. 

technique  of.  496. 
Initial  sclerosis  of  syphilis,  439. 
Injections,  [parenchymatous,  77. 
Injuries,  general  remarks  upon,  288. 
Insects,  injuries  inflicted  by,  410. 
Insolation.  507. 

Instruments,  sterilisation  of,  12. 
Iodine.  171. 

as  an  antiseptic,  171. 

demonstration  in  urine  of,  168. 
Iodine,  trichloride  of,  171. 
Iodoform,  168. 

behaviour  of,  towards  bacteria,  165. 

poisoning  by,  166. 
Iodoform  collodion.  165. 
Iodoform  gauze,  164. 
Iodoform  wick,  165. 
lodol.  169. 

Irrigation,  permanent,  of  wounds,  181. 
Irrigator,  181. 


INDEX. 


837 


Ischsemia,  artificial,  54. 

Ischtemic  contractures.  569. 

Ivory  pegs,  insertion  in  bone  of,  117. 

.Joints,  anatomy  of,  681. 
anchylosis  of,  724. 
cartilage  of,  683. 
contractures  of,  726. 
deformities  of,  726. 

diseases  of,  in  bleeders  (haemophilia),  713. 
echinococcus  of,  680. 
endothelium  of,  681. 
histology  of  articular  cartilages  of,  683. 
inflammations  of,  684. 
acute,  684. 
chronic,  694. 

arthritis  deformans,  710. 
gout,  689. 
syphilis.  708. 
tuberculosis,  699. 
gonorrhoeal,  688. 
metastatic.  687. 
rheumatic,  696. 
injuries  of,  736. 
contusions,  736. 
dislocations,  739. 
gunshot  injuries  of,  755. 
punctured  wounds,  752. 
sprains  or  distortions,  737. 
wounds,  752. 
lymph  vessels  of,  683. 
neuropathic  inflammations  of,  720. 
neuroses  of.  718. 
resection  of,  135. 
synovia  of,  684. 
synovial  villi  of,  682. 
Jimker's  chloroform  apparatus,  25. 
Jury  mast,  231. 
Jute,  155. 

Kappeler's  chloroform  apparatus,  25. 

Keloid,  305,  748. 

Keratoma,  808. 

Knee,  bandages  for,  196. 

Knife,  forms  of,  68. 

methods  of  holding,  69. 
Kyphosis,  701. 

Lacerated  wounds,  477. 
Lancets,  68. 

Laryngeal  mucous  membrane,  anaesthesia 
of,  by  irritation  of,  with  chloroform 
or  carbonic  acid,  48. 
Laughing  gas,  narcosis  of,  44. 

combined  with  oxygen,  45. 
Lead  plates  for  suturing,  115. 
Leather  splints  and  bandages,  215. 
Leg,  bandages  for,  195. 
Leprosy,  450. 

bacilli  of,  451. 

diagnosis  and  prognosis  of,  454. 

occurrence  of,  452. 

symptoms  of,  452. 

treatment  of,  454. 
Leptothrix,  262. 


Leucocytes,    different    reactions   towards 
staining  materials,  299. 

emigration  of,  235. 
Leucocytosis,  inflammatory,  242. 
Lifts  for  sick-bed,  204. 
Ligature  en  masse,  78. 

of  vessels,  93. 
Lightning,  action  of,  506. 
Lint,  155. 
Lipoma,  783. 
Lipoma  arborescens,  716. 
Lister's  method  of  treating  wounds,  153. 
Liver,  collection  of  blood  in  the,  518. 
Lues,  435. 
Lupus,  532. 

Lymph,  movements  of  during  inflamma- 
tion, 236. 
Lymphadenia  ossium,  677. 
Lymphadenitis,  333. 
Lymphangeioma,  793. 
Lymphangieetasis,  564. 
Lymphangitis,  333. 
Lymphatics,  acute  inflammation  of,  333. 

diseases  of,  564. 
Lymph  flstula,  565. 

Lymph   glands,    acute   inflammation    of, 
333. 

collection  of  blood  in,  518. 

diseases  of,  333. 
Lymphoma,  798. 
Lymphorrhagia,  565. 
Lymphorrhoea,  565. 
Lysol,  172. 
Lyssa,  403. 

Madura  foot,  259. 
3Iagnesite  dressing,  225. 
Magnetic  needle  for  extraction  of  metallic 
foreign  bodies,  72,  493. 

for  extraction  of  bullets,  766. 
Malaria,  protozoa  in,  282. 
Malformations,  675. 
Malleus,  397. 

Malum  perforans  pedis,  586. 
Malum  senile,  710. 
Mamma,  dressings  for  the.  192. 
Marly  scraps  for  dressings.  157. 
Marrow  of  bone,  actinomycosis  of.  654. 

chronic  inflammations  of,  643. 

echinococcus  of,  678. 

metastatic  inflammations  of,  641. 

scraping  out  of,  641. 

syphilis  of,  652. 

traumatic  inflammations  of,  641. 

tuberculosis  of.  645. 
Massage,  technique  of,  520. 
Melanoma.  805. 
Menthol  as  angesthetie.  52, 
Mercurial  cachexia,  448. 
Metal  splints.  211. 
Methvl  chloride,  39. 
Methyl  ether,  39. 
Methylene  bichloride.  39. 
Methylene  compounds,  39, 
Methylene  ether,  39. 


838 


INDEX. 


Methylol,  39. 

Microbes,  importance  of,  in  inflammation, 
254. 

importance  of.  in  fever.  312. 

methods  of  examining,  271. 

morphology  of.  2U0. 

of  suppuration,  3:^7. 
Micrococci,  261. 

Micrococcus  pyogenes  tenuis,  331. 
Miliaria,  529.  ' 
Milium.  827. 
Mitella.  200. 
Mitra  Hippocratis,  190. 
Mollin,  187. 

Molluscum  contagiosum,  809. 
Monilia,  257. 
Monoculus,  192. 
Morphine-chloroform  narcosis,  46. 

-ether  narcosis,  47. 
Moss,  156. 
Moss-felt  pads,  156. 
Moss  pulp,  156. 

Mouse  septicaMnia,  bacilli  of,  372. 
Mouth-gag,  26. 
Mouth  speculum.  26. 
IMucor  corymbifer.  258. 

rhizopodoformis.  258. 
Mucous  membrane,  inflammations  of,  544. 

transplantation  of.  149. 
Mull.  155. 

sterilised  pledgets  of,  14. 
Mures  articulares,  714. 
Muscles,  diseases  of,  569,  573. 

hernia  of.  525. 

injuries  of.  522. 

luxations  of.  525. 

regeneration  of.  488. 

suture  of.  482. 

transplantation  of.  482. 
Muscular  rheumatism,  574. 
Mycetozoa,  281. 
Mycosis  fungoides.  544. 
Myoma,  794. 
Myositis  serosa,  570. 

fibrosa,  571. 

ossificans,  571. 
Mvxoedema,  541. 
Myxoma.  783. 
Myxomycetes.  282. 

Xfevus  vasculosus,  790. 

Naphthaline.  170. 

Narcosis  with  chloroform-air  mixture,  35. 

chloroform-morphine.  47. 

chloroform-oxvgen,  35. 

ether,  39. 

by  irritation  of  laryngeal  mucous  mem- 
brane. 48. 

laughing  gas.  44. 

mixed.  45. 
Nearthrosis,  formation  of,  713,  742. 
Neck,  dressings  for,  192. 
Necrosis  of  bone.  655. 

of  soft  parts  (gangrene),  583. 
Necrotomy,  661. 


Needle-holder,  111. 
Needles,  111. 
Nephritis  carbolica,  167. 
Nerves,  defects  of.  486. 

degeneration  of.  after  injuries  of,  468. 

diseases  of,  566. 

grafting,  485. 

injuries  of,  467,  473. 

luxations  of,  526. 

neurectomy.  568. 

regeneration  of,  468,  488,  489. 

stretching  of,  485,  568. 

suture  of.  484. 

transplantation  of.  486. 

treatment  of  defects  of,  485. 
Nervus    phrenicus.   electrical   stimulation 

of.  in  asphyxia,  38. 
Neuralgia,  567. 

of  bones,  720. 

of  joints.  718.  720. 
Neurectomy.  568. 
Neuritis,  566. 
Neurofibroma,  782. 
Neuroglioma  ganglionare,  797. 
Neuroma.  794. 

malignant,  796. 

plexiform,  795. 
Neuropathic  inflammations  of  bones  and 

joints.  720. 
Neurorrhaphy,  484. 

after-treatment  of.  487. 

histological  changes  after,  490. 

results  of,  488. 

secondary,  485. 
Neuroses,  traumatic,  285,  567. 

folloNving  opei'ations.  68. 
New  formation  of  tissue.  290. 
Ne\y  formation  of  vessels,  293. 
Noma,  584. 

Occlusion,  antiseptic,  in  army  surgery,  761. 
Occlusive  dressings,  antiseptic,  153. 
Odontoma,  788. 
Qidenia.  malianant,  339. 

bacilli  of,  339. 
Oidium,  257. 
Oil-cvsts,  829. 
Onychoma.  808. 
Operating  tables.  6.  7. 
Operation.  1. 

accidents  in  the  course  of,  61. 

after-treatment  of,  66. 

alleviation  of  pain  in,  17. 

aseptic.  2. 

causes  of  death  in.  67. 

definition  of.  1. 

healing  of  wounds  made  in  the  course 
of.  66.  280. 

indications  and  contra-indications,  2. 

neuroses  following.  68. 

preparations  for.  2. 

preparations  for,  in  private  practice,  15. 

saving  of  blood  during,  53. 
Operator,  clothing  of.  10. 

disinfection  of  clothing  of,  10. 


INDEX. 


839 


Organisation  of  a  thrombus,  296. 
Osteoblasts,  603. 
Osteochondritis,  653,  663. 

dissecans,  662. 

luetiea,  653. 
Osteoclasis,  91. 
Osteoclastic  cells,  604. 
Osteoclasts,  91,  583. 
Osteoma,  787. 
Osteomalacia,  669. 

anatomical  changes  in,  669. 
Osteomyelitis,  acute  primary,  634. 

anatomical  changes  in,  636. 

clinical  course  of,  637. 

diagnosis  and  prognosis  of,  689. 

etiology  of,  635. 

treatment  of,  639. 
Osteomyelitis,  chronic,  643. 

syphilitic,  652. 

tubercular,  645. 
anatomical  changes  in,  646. 
clinical  course  of,  648. 
diagnosis  and  prognosis  of,  649. 
treatment  of,  650. 
Osteophyte,  644. 
Osteoplasty,  629. 
Osteoporosis,  673. 
Osteopsathyrosis,  593. 
Osteosarcoma,  789. 
Osteosclerosis,  674. 
Osteotome,  87. 
Ostitis,  633.  ■ 

Paper-starch  dressing,  224. 
Papier-mache  splints,  214. 
Papilloma,  807. 
Paquelin's  thermo-cautery,  79. 
Paralysis  of  heart  from  chloroform,  30. 

electro-puncture  for,  38. 
Paralysis,  infantile  spinal,  731. 
Parenchymatous  injections,  77. 
Paronychia,  342. 
Peat,  156. 

Pelvis,  bandages  for,  197. 
Pemphigus,  529. 
Penicillium  glaucum,  256. 
Pental  narcosis,  48. 
Percussion  of  bone,  616. 
Percutaneous  ligation  (of  vessels),  98. 
Periarteritis.  336. 

Periosteum,  inflammations  of,  633. 
Periostitis,  albuminoid  or  mucinoid,  643. 

chronic  ossifying,  644. 

syphilitic,  652. 

tubercular,  645. 
Periphlebitis,  336. 
Peroxide  of  hydrogen,  171. 
Pes  calcaneus  paralyticus,  730. 

equino  paralyticus,  729. 

valgus,  728. 

varus,  726. 
Petit's  leg  splint,  206. 
Phagocytes,  276. 
Phenol,  157. 
Phlebectasise,  560. 


Phlebitis,  336. 

Phlebotomy,  472. 

Phlegmasia  alba  dolens.  346. 

Phlogosin,  242. 

Phosphorus  necrosis,  656. 

Photoxvlin.  186. 

Plasmodia,  282. 

Plasmodiophora  Brassiere,  282. 

Plasmodium  malaria?,  282. 

Plaster  of  Paris,  splints  of,  217. 

Plastic  operations,  140. 

Plexiform  neuroma,  795. 

Pneumococcus,  332. 

Poison,  cadaveric,  386. 

Poisoning  by  insects  and  snakes,  410. 

Poultice,  antiseptic,  183. 

Pressure  paralysis  from  cicatrix,  305. 

Projectiles     from     firearms,     effects     of, 

758. 
Protozoa,  281. 
Pseudarthrosis,  614. 
Pseudo-diphtheria.  550. 
Pseudo-tuberculosis,  420. 
Ptomaines,  267. 
Pulse  in  fever,  310. 
Punctured  wounds,  470. 

of  cavities,  473. 

of  joints,  473,  752. 

of  nerves,  473. 

of  vessels,  471. 
Pus.  247. 

blue.  249,  330. 

green,  249,  330. 

red,  249,  331. 
Pus-corpuscles,  origin  of,  248. 
Pus  microbes,  327. 
Putrefaction,  bacteria  of,  373. 
Pytemia,  380. 

clinical  course  of,  382. 

diagnosis  of,  385. 

etiology  of,  380. 

occurrence  of,  382. 

pathology  of,  381. 

prognosis  of;  385. 

treatment  of,  385. 

Rabies.  403. 
Railway  injuries,  285. 
Reaction   following   injurv  or   inflamma- 
tion, 305. 
Red  pus,  331. 
Regeneration  of  tissues,  251.  303. 

of  nerves,  469,  489. 

of  tendons,  469,  484. 
Reproduction  of  bacteria,  263. 
Respiration,  artificial,  37. 
Retractors.  73. 

Reunion  of  entirelv  severed  parts,  295. 
Rhachitis.  663. 

anatomical  changes  in,  664. 

the  course  of,  667. 

the  diagnosis  of,  668. 

the  etiology  of,  667. 

the  treatment  of,  668. 
Rontgen-rays,  766. 


840 


INDEX. 


Saccharomyces,  259. 
Salicvlic  acid,  161. 
Salves,  186. 

Scab,  healing  under  a,  180. 
Scissors,  74. 

Schleich's  anaesthesia,  51. 
Scleroderma,  543. 
Scrofula,  treatment  of,  434. 
Scurvy  or  scorbutus,  539. 
Septicamiia,  369. 
of  animals,  371. 
clinical  course  of,  375. 
cryptogenetic,  370. 
diagnosis  of,  378. 
etiology  of,  370. 
occurrence  of,  374. 
pathological  changes  in,  374, 
prognosis  of,  378. 
treatment  of,  379. 
Sequestrotomy,  661. 
Sequestrum,  separation  of,  657. 
Shock,  319. 

etiology  of,  319. 
symptoms  of,  320. 
treatment  of,  321. 
Shot-suture,  115. 
Silk,  preparation  of,  94. 
Skin,  burns  of,  499. 
callosities  of,  808. 
contusions  of,  475,  513. 
diseases  of,  526. 
frost-bites  of,  509. 
horns  of,  808. 
injuries  of,  462. 
opening  for  drainage,  105. 
plastic  operations  upon,  140. 
polypus  growths  of,  829. 
transplantation  of,  146. 
Skin-grafting,  146. 
Skin-muscle  canalisation,  108. 
Skinning  over  of  granulation  wounds,  288. 
Snake-bites,  410. 

Sodium   chloride,   addition  to  bichloride 
solution  of,  161. 
impregnation  of  dressings  with,  157. 
for  treatment  of  wounds,  173. 
Sodium-chloride  infusion.  494. 
Sodium  tetraboricum,  163. 
Soft  ehanci'e,  444. 
Spastic  stiffness  of  joints,  729. 
Spirillum,  262. 

Splints  of  plaster  of  Paris,  217. 
Spoon,  sharp.  77. 
Sprains  of  joints,  737. 
Spray,  15. 

Starch  dressing,  228. 
Steam  spray.  15. 
Steam  sterilising  apparatus,  4. 
Stenocarpine,  52. 
Sterilisation  of  catgut,  94. 
of  dressings,  14. 
of  instruments,  12. 
of  silk,  14. 
Sticking-plaster,  extension  by,  227. 
various  kinds  of,  185. 


Sticking-plaster,  mull,  185. 
Streptococcus  pyogenes.  329. 
Structure  and  reproduction  of  bacteria,  262. 
Subcutaneous  rupture  of  muscles  and  ten- 
dons, 522. 

treatment  of,  524. 
Subcutaneous  salt  infusion.  498. 
Sulphocarbolate  of  zinc,  170. 
Sun-burn,  507. 
Sun-stroke,  507. 

treatment  of,  509. 
Suppuration,  causes  of,  241. 

importance  of  microbes  in,  324. 

various  kinds  of,  245. 

various  kinds  of  microbes  of,  326. 
Suspension  apparatus,  207. 
Suture,  continuous,  114. 

interrupted,  113. 

of  nerves,  484. 

secondary,  116. 

of  tendons,  480. 

of  vessels,  98. 
Suture  materials,  113. 
Syncope,  30. 
Syphilis,  435. 

changes  in  blood  in,  442. 

course  of.  442. 

immunity  from,  444. 

inheritance  of,  437. 

origin  of,  436. 

symptoms  of,  439. 

transmission  of,  to  animals,  436. 

treatment  of,  444. 
Syphilitic  albuminuria,  443. 

dental  deformities,  443. 

pseudo-paralysis,  443. 

Temperature  of  body  in  fever,  306. 

Temporary  dressings,  197. 

Tenoplasty,  482. 

Tenorrhaphy,  480. 

Tenosynovitis,  578. 

Tenotome,  71. 

Tenotomy,  580. 

Teratoma,  828. 

Terebene,  170. 

Tetanus,  bacillus  of,  363. 

clinical  course  of,  366. 

etiology  of,  361. 

of  the  head,  367. 

hydrophobicus,  367. 

immunity  from,  365. 

pathogenesis  of,  367. 

poison  of,  364. 

prognosis  of,  368. 

traumatic,  360. 

treatment  of,  368. 
Tetany,  365. 

Tetraboride  of  sodium,  163. 
Thermo-cautery,  Paquelin's.  79. 
Thrombus,  organisation  of,  296. 

red,  white,  and  mixed,  297. 

subsequent  changes  in,  300. 
Thymol,  162. 
Tissue,  division  of,  68. 


INDEX. 


841 


Tissue,  formation  of,  288. 

regeneration  of,  351,  303. 
Toothed  forceps,  73. 
Tourniquets,  55. 
Toxines,  367. 
Transfusion  of  blood,  494r498. 

dangers  of,  495. 

indications  for,  496. 

technique  of,  496. 
Trichloride  of  iodine,  171. 
Tripolith  dressing,  223. 
Trismus,  361. 
Trocar,  75. 

Tubercle,  anatomical,  387. 
Tubercle  bacilli,  416. 

of  birds,  420. 

demonstration  of,  423. 

staining  of,  418. 

toxine  of,  417. 
Tubercles,  origin  and  structure  of,  415. 
Tuberculosis,  414. 

of  bones  and  joints,  428. 

of  cattle,  420. 

combined    with    syphilis    and    cancer, 
421. 

diagnosis  of,  428. 

extension  of,  423. 

inheritance  of,  434. 

of  lips,  rectum,  etc.,  427. 

of  lymph  glands,  428. 

of  mucous  membranes,  426. 

of  nose,  437. 

origin  of,  in  man,  431. 

of  pharynx,  palate,  etc.,  426. 

prognosis  of,  438. 

of  subcutaneous  tissue,  435. 

termination  of,  433. 

of  tongue,  436. 

transmission  of,  to  animals,  419. 

transmission  of,  to  foetus,  434. 

treatment  of,  439. 

treatment  of,  with  tuberculin,  431. 
Tumours,  769. 

in  animals,  773. 

clinical  course  of,  773. 

curability  of  malignant,  776. 

diagnosis  of,  776. 

etiology  of,  770. 

growth  of,  774. 

transmissibility  of,  773. 

treatment  of,  776. 


Tumours,  various  kinds  of,  with  their  treat- 
ment, 776. 

Ulcers,  cicatricial,  305. 

irritable,  540. 

of  skin,  536. 
Urine,  condition  of,  in  fractures.  603. 

condition  of,  in  rhachitis,  666. 

Vaccination  lancet,  69. 
Varices,  560. 
Venesection,  473. 
Verruca  neerogenica,  387. 
Vessels,  behaviour  of,  in  fever,  310. 

formation  of  cicatrix  in,  800. 

formation  of  new,  293. 

ligation  of,  93. 

ligation  of,  en  masse,  97. 

other  methods  of  hsraostasis,  99. 

suture  of,  98. 
Vibrio,  262. 
Villi,  synovial,  682. 

Wandering  of  the  acetabulum,  701. 

Water-glass  dressing,  224. 

Whitlow,  342. 

Wire  splints  and  gutters,  213. 

Wire  stocking.  Bonnet's,  313. 

Wood-fibre  dressing,  156. 

Wood-fibre  pads,  156. 

Wooden  splints,  307. 

Wood  wool,  156. 

Wound  pain,  463. 

Wounds,  foreign  bodies  in,  475. 

gaping  of,  463. 

haemorrhage  from,  463. 

healing  of,  386. 

infectious  diseases  of,  323. 

inflammation  and  suppuration  of,  326. 

of  muscles  and  tendons,  467. 

of  nerves,  467. 

repair  of,  in  non-vascular  tissues,  303. 

of  soft  parts,  462. 

suture  of,  110. 

symptomatology  of,  462. 

treatment  of,  478. 

Xanthoma,  804. 
Xeroform,  169. 

Zinc,  sulphocarbolate  of,  170. 


THE    END. 


A  TREATISE  ON  THE 
DISEASES   OF  WOMEN. 

By  ALEXANDER  J.    C.   SKENE,  M.  D., 

PBOFESSOR    OF    GTU^COLOGT    IN  THE  LONG    ISLAND  COLLEGE    HOSPITAL,   BROOKLYN,    N.   Y.  ;    FOB- 

MERLY    PROFESSOR    OP    GYNECOLOGY    IN    TKE    NEW    YORK    POST-GRADUATE    MEDICAL 

SCHOOL    AND    HOSPITAL,    ETC. 


Third  Edition,  revised  and  enlarged.     8vo,  991  pages.     With  290  Fine 

"Wood  Engravings,  and  Nine  Chromolithographs,  prepared 

especially  for  this  work. 

SOLD  ONLY  BY  SUBSCRIPTION. 

THIS  attractive  work  is  the  outcome  and  represents  the  experience  of  a  long  and 
active  professional  life,  the  greater  part  of  which  has  been  spent  in  the  treat- 
ment of  the  diseases  of  women.  It  is  especially  adapted  to  meet  the  wants 
of  the  general  practitioner,  by  enabling  him  to  recognize  this  class  of  diseases  as 
he  meets  them  in  every-day  practice  and  to  treat  them  successfully. 

The  arrangement  of  subjects  is  such  that  they  are  discussed  in  their  natural 
order,  and  thus  are  more  easily  comprehended  and  remembered  by  the  student. 

Methods  of  operation  have  been  much  simplified  by  the  author  in  his  practice, 
and  it  has  been  his  endeavor  to  so  describe  the  operative  procedures  adopted  by 
him,  even  to  their  minutest  details,  as  to  make  his  treatise  a  practical  guide  to  the 
gynaecologist. 

While  attention  has  been  given  to  the  surgical  treatment  of  the  diseases  of 
women,  and  many  of  the  operations  so  simplified  as  to  bring  them  within  the 
capabilities  of  the  general  surgeon,  due  regard  has  also  been  paid  to  the  medical 
management  of  this  class  of  diseases. 

Although  all  the  subjects  which  are  discussed  in  the  various  text-books  on 
gynecology  have  been  treated  by  the  author,  it  has  been  a  prominent  feature  in 
his  plan  to  consider  also  those  which  are  but  incidentally,  or  not  at  all,  mentioned 
in  the  text-books  hitherto  published,  and  yet  which  are  constantly  presenting 
themselves  to  the  practitioner  for  diagnosis  and  treatment.       ' 

"In  the  preface  of  the  first  edition  of  this  work  the  author  states  :  'This  worli  was  written  for 
the  purpose  of  bringing  together  the  fully  matured  and  essential  facts  in  the  science  and  art  of 
gynaecology,  so  arranged  as  to  meet  the  requirements  of  the  student  of  medicine,  and  be  convenient 
to  the  practitioner  for  reference.'  The  demand  for  a  second  edition  has  demonstrated  how  fully 
this  purpose  has  been  accomplished.  The  reader  can  not  fail  to  commend  the  conservatism  and 
honesty  of  the  author 's  opinions,  and  the  care  with  which  the  material  has  been  collected  and 
arranged.  The  second  edition  contains  new  chapters  on  Ectopic  Gestation,  Diseases  and  Injuries 
of  the  Ureters,  and  Vesical  Hernia.  The  first  of  these  subjects  receives  in  this  edition  a  careful 
exposition,  the  want  of  which  was  among  the  few  defects  of  the  former  edition.  The  author's 
work  in  the  positional  disorders  of  the  uterus  and  laceration  of  the  perinseum  stands  pre-eminent 
among  the  contributions  to  this  subject.  His  discussion  of  the  use  of  pessaries  throws  much  light  upon 
a  subject  which  has  suffered  from  the  want  of  careful  treatment,  both  ^;ro  and  can.  The  publishers 
deserve  great  credit  for  the  illustrations  and  general  style  of  the  work."— Medical  Neivs. 

"We  have  very  little  to  add  to  what  we  said  of  it  on  its  first  appearance,  and  we  still  regard  it  as 
one  of  the  few  foremost  books  in  this  department  in  the  English  language.  The  addition  of 
chapters  on  Diseases  and  Injuries  of  the  Ureters,  and  on  Ectopic  Gestation,  make  it  more  complete. 
Too  much  praise  can  not  be  given  to  the  illustrations,  which  are  models  of  clearness,  and,  as  is  not 
always  the  case,  show  what  is  meant." — Boston  Medical  and  Surgical  Journal. 


T>.  APPLETON   AND   COMPANY,  NEW  YORK. 


THE  DISEASES  OF  THE 
STOMACH. 

By    Dr.    C.    A.    EVV^ALD, 

EXTRAORDINARY    PROFESSOR    OF    MEDICINE    AT    THE    INIVEItSITY    OF    HERI-IX. 

ISecond  Atneiican  Edition,  translated  and  edited,  ivith  iiumerous  Adiiitioiis, 
from  the  Third  German  Edition, 

By  MORRIS    MANGES,   A.  M.,   M.  D., 

ASSISTANT    VISITING    PHVSICIAX    TO    MOUNT    SINAI    HOSPITAL:     LECTLREU   ON 
GENERAL    MEDICINE,    NEW    TOBK     POLYCLINIC,    ETC. 

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"In  giving  the  medical  profession  this  second  revised  translation  of  Prof. 
Ewald's  treatise  on  the  Diseases  of  the  Stomach,  Dr.  Manges  has  placed  the  profes- 
sion  under  even  greater  obligations  than  we  owed  for  the  first.  The  first  transla- 
tion was  then  an  almost  exhaustive  treatise,  and  now,  with  so  much  new  and 
valuable  data  added,  the  work  is  a  sine  qua  non." — Atlanta  Medical  and  Surgical 
Journal. 

"  This  work  as  it  now  stands  is  the  best  on  the  subject  of  stomach  diseases  in 
the  English  language.  No  physician's  library  is  complete  without  it.  It  is  in 
every  way  well  adapted  to  the  requirements  of  the  general  practitioner,  although 
complete  enough  to  meet  also  the  requirements  of  the  specialist." — American 
Medico- Surgical  Bulletin. 

"  The  present  American  edition  is  a  peculiarly  valuable  one,  as  the  editor. 
Dr.  Manges,  has  done  his  work  in  a  thoroughly  creditable  manner.  His  numer- 
ous notes,  additions,  and  new  illustrations  have  made  the  book  a  classic  one. 
Under  these  circumstances  it  should  find  a  place  in  the  library  of  every  Amer- 
ican physician,  as  their  clientele  is  composed  of  such  a  large  proportion  of  patients 
suffering  from  gastric  complaints  and  more  or  less  improper  medication  which 
most  often  ends  in  failure.  There  is  no  doubt  that  more  properly  directed  efforts 
in  the  proper  direction,  as  outlined  in  Ewald's  book,  would  soon  remove  from 
Americans  the  reputation  of  being  a  nation  of  dyspeptics." — St.  Louis  Medical 
and  Surgical  Journal. 

"  Dr.  Ewald's  book  has  met  with  a  very  cordial  reception  by  the  medical  pro- 
fession. Within  a  short  period  three  editions  have  appeared,  and  translations 
published  in  England,  Spain,  France,  Italy,  and  the  United  States.  To  the 
present  edition  the  author  has  not  only  added  considerable  new  matter,  but  he 
has  also  entirely  rewritten  the  work.  The  arrangement  of  the  chapters  has  been 
somewhat  changed,  and  many  new  personal  observations  and  therapeutic  experi- 
ences added.  The  desirability  of  surgical  interference  is  carefully  considered,  and 
the  pros  and  cons  given  so  far  as  would  be  necessary  to  enable  a  physician  to 
determine  whether  the  aid  of  the  surgeon  might  be  required.  The  translator  has 
done  his  work  well,  and  has  incorporated  much  new  matter  into  the  text  and 
footnotes." — North  American  Journal  of  Homoeopathy. 


D.  APPLETON  AND  COMPANY,  NEW  YOPwK. 


THE  DISEASES  OF 

mnmj  km  childhood. 

J^or  the  Use  of  Students  and  Practitioners  of  Medicine. 
By  L.  EMMETT  HOLT,  A.  M.,  M.  D., 

Professor  of  Diseases  of  Children   in   the  New   York  Polyclinic  ;   Attending  Physician  to 

the  Babies'  Hospital  and  to  the  Nursery  and    Child'' s   Hospital^  New   York  j 

Consulting  Physician  to  the  New  York  Infant  Asylum,  and  to  the 

Hospital  for  Ruptured  and  Crippled. 

With  7  full-page  Colored  Plates  and  203  Illustrations.     Cloth,  $6.00  , 
sheep,  $7.00  ;  half  morocco,  $7.50. 

SOL.X)    ONLY    BY    SXJBSCKIPTIOJ^. 


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"  This  work  is  in  every  sense  of  the  word  a  new  book  ;  for,  while  the  best  work  of  other 
authors  in  this  and  other  countries  has  been  drawn  upon,  especially  that  in  the  form  of 
monographs  and  in  the  tiles  of  psediatric  literature,  the  majority  is  derived  from  the  author's 
own  clinical  observations.  Obsolete  dicta  handed  down  from  text-book  to  text-book  are 
here  conspicuously  absent,  and  nothing  has  been  accepted  which  has  not  been  carefully 
tested.  ...  It  is  not  venturing  too  much,  after  a  careful  perusal  of  these  pages,  to  predict 
for  this  volume  a  pre-eminent  and  lastinsr  position  among  the  treatises  upon  this  subject. 
We  heartily  recommend  that  it  find  a  place  not  only  in  the  library  of  every  physician,  but 
wide  open  at  the  elbow  of  every  man  who  desires  to  deal  intelligently  with  the  problems 
which  confront  him  in  the  treatment  of  infants  and  children  intrusted  to  his  care." 

Nashville  Journal  of  Medicine  : 

"  This  magnificent  work  is  one  of  the  most  valuable  recent  contributions  to  medical  liter- 
ature. It  will  rapidly  vnn  its  way  to  a  front  rank  with  other  standard  works  upon  kindred 
subjects.     It  is  as  nearly  complete  as  a  treatise  upon  this  subject  can  be." 

Virginia  Medical  Semi-Monthly  : 

"  When  one  recalls  the  teachings  of  a  decade  or  two  ago  and  compares  the  inculcations 
of  to-day,  he  can  scarcely  help  recognizing  that  '  old  things  have  passed  away,  and  all 
things  have  become  new.'  The  volume  before  us  is  practically  the  record  of  information 
obtained  by  the  author  from  eleven  years  of  special  study  and  practice,  so  that  nearly  every 
subject  is  presented  from  the  standpoint  of  personal  observation  and  experience.  The 
information  given  is  therefore  reliable,  for  Dr.  Holt  is  a  close  observer  and  a  careful  student 
of  his  ripe  experience.  ...  In  short,  this  book  appears  to  us  to  be  the  best  all-round,  up-to- 
date  book  for  practitioners  and  students  of  children's  diseases  that  we  know  of." 

Medical  Progress : 

"  The  work  before  us  is  one  which  reflects  great  credit  upon  the  distinguished  author. 
Dr.  Holt  has  long  been  known  as  a  most  industrious  and  painstaking  investigator,  and  in 
this  volume  he  sustains  that  reputation.  The  work,  we  may  say  in  a  sentence,  is  fully  up 
to  the  requirements  of  the  times,  and  there  is  no  advance  known  to  pediatrics  which  has 
not  been  fully  dealt  with  according  to  its  merits." 


D.   APPLETON  AND   COMPANY,   NEW   YORK. 


A  TEEATISE 

OX   DISEASES   OF   THE 

EECTI3I.  AXrS,  A^-i5 

SIGMOID  FLEXUEE. 

By  JOSEPH  M.  :yiATHEWS.  M.  D.. 

OF  LOnSVIIXB.   KT.. 
PrOFSSSOB   O?  TH2   P3ZS":i?:.Z5   A2rD   PkaCTICE  O?   Srp.C-ZBT.  Jl>-T)   Clixicjll  LEcrrBKR 

■.y  r>i5EA;£5   :?  thz  P.zcm:,  nc  the  Kz^rrcEr 
ScHooi  OF  Medicixe,  etc. 

"With  Six  Cliroiiiolithoffraphs   and   numerous   Illustrations  in  the  Text. 
SmCOND  EDITION,   REVISED. 

8vo,  537  xDages.     Cloth  binding.  So. 00. 


SOLD    OyZY  BY  SUB-SCBlPTIOy. 


*•  The  author  has  placed  before  the  profession  the  firuits  of  fifteen  vears'  experience  as  a 
rectal  specialist.  ...  A  carefiil  penisal  of  Mathews's  work  can  not  fail  to  give  the  practi- 
tioner all  the  knowledge  that  is  desirable  to  soccessfiillT  diagnosticate  and  treat  any  case  of 
rectal  disease  that  may.  come  before  him,  if  he  possesses  a  modicom  of  the  dexterity  that  an 
ordinary  surgeon  should  have.  .  .  .  The  book  ii  rich  in  clinical  material,  and,  in  the  writer's 
opinion^  is  tEe  best  work  on  this  specialty  yet  published.  The  publishers  have  done  their 
work  well,  the  six  chromolithographs  being  artLsticL" — Chicago  Medual  Reeordar, 

"...  The  work  is  a  most  practical  and  classical  presentation  of  the  vast  and  varied 
experience  of  a  painstaking  observer  and  worker.  The  specialist  will  buT  it  and  read  it, 
o^erwise  he  womd  not  be  prtKiessive.  The  general  practitioners,  above  alt,  should  procure 
and  read  this  book,  for  the  reason  that  it  wiU  at  least  assL»-t  them  in  making  a  correct 
diagnosis ;  and,  if  they  care  to  treat  tbese  diseases,  it  gives  them  all  that  is  newest  and 
best." — Mediml  Mirror. 

'•  This  book  we  think  is  decidedly  original  in  many  of  its  features.  The  author  ha?  not 
taken  other  men's  opinions  as  his  guide,  for  the  reason  that  in  his  fifteen  years'  experience 
as  a  rectal  specialist  he  has  learned  *  that  macy  things  that  are  taught  are  not  true,  and  that 
many  true  things  have  not  been  taught.'  He  has  therefore  accepted  as  truths  only  those  things 
which  could  be  substantiated  by  mrts,  and  has  here  recorded' them.  Several  chapters  new 
to  books  on  this  subject  have  been  introduced  by  him,  among  which  will  be  found  the  follow- 
ing :  Disease  in  the  Sigmoid  Flexure,  the  Hvsterical  or  Nervous  Bectum^  Anatomy  of  the 
B^-tum  in  Belation  to  Befiexes.  Antiseptics  in  fiectal  Surgery,  and  a  Xew  Operation  for  Fistula 
in  Ano.  .  .  .  niastrated  with  six  excellent  colored  pJates  and  numerous  cuts ;  cleariy  printed 
with  lai^  typ«.  and  nicely  bound,  it  presents  a  most  attractive  appearance.  We  do  net 
know  of  any  work  on  the  subject  wbi^  more  thoroughly  meets  our  approTaL" — JfempAu! 
Hedieal  Monthly. 

D.    APPLETOX    AND    COMPANY.  NEW  YORK 


A  PRACTICAL  TREATISE  ON  THE 

SURGICAL.  DISEASES 

OF  THE  GENITO-URINARY 

ORGANS, 

INCLUDING  SYPHILIS. 

"DESIGNED  AS  A  MANUAL  FOR  STUDENTS  AND  PRACTITIONEES.. 

With  Engravings. 

By  E.  L.  KEYES,  A.M.,  M.  D., 

Professor  of  Genito-Urinary  Surgery,  Syphilology,  and  Dermatology 
in  Bellevue  Hospital  Medieal  College. 

BEING  A  BEYISION  OF  A   TEEATISE,  BEARING   THE  SAME   TITLE,  BY 
YAN  BUPlEN  and  KEYES. 

SECOND   EDITION,   THOEOUGHLY   REVISED,   AND  SOMEWHAT   ENLARGED. 


8vo.    688  pages.    Cloth,  $5.00 ;  sheep,  $6.00. 

"  The  progress  made  in  surgery  during  the  last  ten  years,  the  changes  of  practice  by  th& 
best  surgeons  with  regard  to  sev"eral_  operative  procedures,  notably  litnolapaxy,  suprapubic 
cystotomy,  and  operations  upon  the  kidney  itself,  and  other  matters  as  -well,  rendered  neces- 
sary a  thorough  revision  of  the  work  published  some  years  ago  as  the  joint  production  of  Drs, 
Van  Buren  and  Keyes.  Much  of  the  work  I; as  been  rewritten  entirely.  There  is  a  lar^e 
amount  of  entirely  new  matter  presented  in  tliis  volume,  to  make  room  for  which  the  reports 
of  cases  given  in  the  former  work  are  all  on  itted  in  this.  The  work  in  its  present  form 
stands  fairly  abreast  of  the  latest  advances  it  genito-urinary  surgery.  Dr.  Keyes  says  or 
the  book  that  it  is  an  honest  exhibit  of  his  view,  upon  all  the  subjects  considered,  and,  in  "view 
of  his  wide  experience  and  unquestioned  skill,  ^e  commend  his  book  to  the  notice  and  study 
of  all  who  work  in  this  field." — St.  Louis  Courier  of  Medicine. 

"  We  do  not  know  of  any  one  work  in  the  English  language,  devoted  to  diseases,  etc.,  oi 
the  genito-urinary  organs,  including  the  venereal  diseases,  that  is  so  well  adapted  to  tte  wants 
of  the  general  practitioner.  To  the  specialist  this  book  is  invaluable." — Virginia  Medicat 
Monthly. 

"  This  handsome  volume  is  not  merely  a  new  edition  of  the  well-known  work  of  Tan  Buren 
and  Keyes,  but  a  complete  revision  of  that  text-book.  The  original  plan  of  the  older  work 
has  been  retained,  and  its  scope  remains  the  same  ;  but  it  has  been  entirely  recast,  and  in  ■: 
large  measure  rewritten.  This  course  has  been  made  necessary  by  the  vast  progress  which 
has  marked  the  history  of  surgery  during  the  last  ten  years,  especially  in  the  field  of  thera- 
peutics and  operative  procedures.  To  bring  the  book  up  abreast  of  the  times  upon  the  new 
device  of  litholapaxy,  suprapubic  cystotomy,  the  modem  surgery  of  the  kidney,  the  treat- 
ment now  followed  in  diseases  of  the  tunica  vaginaUs,  and  the  many  minor  changes  which 
find  expression  in  the  use  of  new  agents,  Dr.  Keyes  was  compelled  to  omit  many  things,  to 
add  considerable  new  matter,  and  largely  to  modi'ty  much  of  the  remainder.  Soine  chapters 
are  entirely  new,  and  in  order  to  make  room  for  desired  additions  all  the  cases  have  been 
dropped.  As  it  now  stands,  it  is  a  treatise  which  may  safely  be  consulted,  and  which  fairly 
and  freely  speaks  of  the  most  modern  methods.  Dr.  Keyes  is  enthusiastic  in  his  commenda 
tions  of  litholapaxy.  and  cordially  indorses  the  high  operation  for  stone,  while  he  decides 
that  the  time-honored  and  brilliant  methods  of  reaching  the  bladder  through  the  perineum 
ire  only  applicable  in  the  cases  of  male  children  with  stones  of  moderate  size.  Dr.  Keyes 
says  the  book  '  is  an  honest  exhibit  of  my  views  upon  all  the  subjects  considered ' ;  and  as  his 
experience  has  been  large,  and  his  skiU  and  prudence  are  undisputed,  we  have  no  hesitation 
in  sayintc  there  is  no  one  in  this  country  whose  judgment  is  more  worthy  of  confidence,  or 
whose  directions  may  be  more  safely  fullowed." — American  .Journal  of  tlie  Medical  Scienc^e, 


D.   APPLETON    AND    COMPANY,  NEW   YORK 


DISEASES  OF  THE  EAR. 

A   TEXT-BOOK  FOR  PRACTITIONERS 
AND   STUDENTS  OF   MEDICINE. 

B\-  Edward  Bradford  Dench,  Ph.  B.,  M.  D., 

Professor  of  Otology  in  the  Bellevue  Hospital  Medical  College  ;  Aural  Surgeon  to  the 
New  York  Eye  and  Ear  infirmary,  elc. 

Second  Edition.     8vo,  6^j  pages. 
With  8  Colored  Plates  and  152  Illustrations  in  the  Text. 

Cloth,  S5-00;  sheep,  S6.00. 

"An  examination  of  the  contents  will  prove  that  this  volume  carries  its  raison 
d'etre.  It  embodies  in  a  most  satisfactory  manner  the  known  facts  of  otology,  hav- 
ing incorporated  most  successfully,  and  with  little  bias,  the  recent  advancements  that 
have  been  made  in  this  branch.  Recognizing  the  aid  which  comes  from  a  faithful 
reproduction  of  the  anatomical  structures  concerned,  and  from  showing  the  site  of 
operative  procedures,  the  plates  have  been  prepared  with  all  the  care  and  precision  of 
modern  engraving  art  from  the  specimens  themselves.  The  high  class  of  illustrations 
in  the  work  is  worthy  of  special  praise.  The  text  maintains  a  character  that  will  rank 
the  author  as  one  of  our  best  otological  writers.  He  has  paid  marked  attention  to  the 
physiological  basis  of  aural  studies  and  to  the  functional  examination  in  cases  of  ear 
disease.  In  mentioning  treatment  he  has  gone  into  manipulative  details  that  other 
writers  have  omitted,  and  yet  which  are  verj'  necessary  to  the  student  and  practitioner 
who  may  have  never  had  a  chance  to  study  and  observe  these  matters  in  special  aural 
clinics.  The  author  is  perhaps  more  fond  of  operative  procedures  in  middle-ear  dis- 
ease than  some  of  his  colleagues,  but  he  has  given  us  what  we  have  desired — a  good 
modern  rhumd  o-a  the  benefits  to  be  derived  from  such  operations." — Colutnbus  Aled- 
ical  JoufTtal. 

"  One  has  only  to  read  this  volume  in  order  to  see  its  worth.  Whether  there  was 
need  at  present  for  a  new  text-book  on  otology  must  be  seen  from  the  success  which 
will  be  met  with  by  this  work  of  Dr.  Dench.  However,  we  have  no  hesitancy  in  say- 
ing that  it  is  the  best  work  of  its  kind  by  an  American  author.  Dr.  Dench  is  perhaps 
one  of  the  leading  exponents  of  intra-tympanic  surgery,  and  while  his  views  upon  this 
subject  are  perhaps  more  radical  than  the  majority  of  aural  surgeons,  yet  they  must 
be  thoughtfully  considered,  coming  as  they  do  from  one  who  is  so  well  and  favorably 
kno^vn.  It  is  almost  impossible  to  display  any  originality  in  writing  a  work  upon  the 
ear,  yet  in  this  text-book  the  author  has  dealt  in  no  superficial  vagaries,  but  he  speaks 
as  one  with  a  large  amount  of  clinical  experience,  and  thus  gives  to  the  reader  those 
points  which  are  of  practical  importance." — Atlanta  Medical  and  Surgical  Journal. 

"  In  this  valuable  work  minute  patholog)'  has  not  been  considered  extensively,  be- 
cause it  has  been  the  aim  of  the  author  to  adapt  it  to  the  needs  of  the  general  prac- 
titioner and  special  surgeon.  Dr.  Dench  has  written  at  length  upon  the  importance 
of  a  thorough  functional  examination,  which  many  works  upon  otology'  have  failed  to 
emphasize.  He  has  placed  the  results  of  recent  investigations  at  the  disposal  of  the 
reader  in  such  a  manner  as  to  enable  him  to  use  them  in  diagnosis.  The  author  has 
written  from  his  extensive  personal  experience  in  advocating  operative  procedures 
upon  the  middle  ear.  On  the  whole  the  work  is  an  exceedingly  good  one,  and  admi- 
rably adapted,  as  was  the  author's  aim,  to  the  general  practitioner  and  the  special 
surgeon." — Kansas  City  Medical  Record. 


D.   APPLETOX    AXD    COMPANY,    NEW   YORK. 


